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UNiTED STATES OF AMERICA. 



HYSTERIA 



AND ALLIED CONDITIONS 



PRESTON 



HYSTERIA 



CERTAIN ALLIED CONDITIONS 



THEIR NATURE AND TREATMENT, WITH SPECIAL REF- 
ERENCE TO THE APPLICATION OF THE REST CURE, 
MASSAGE, ELECTROTHERAPY, HYPNOTISM, ETC. 



GEORGE J. PRESTON, M.D. 

PROFESSOR OF DISEASES OF THE NERVOUS SYSTEM, COLLEGE OF PHYSICIANS AND SURGEONS, 

BALTIMORE ; VISITING PHYSICIAN TO THE CITY HOSPITAL ; CONSULTING NEUROLOGIST 

TO BAY VIEW ASYLUM, THE HEBREW HOSPITAL, THE CHURCH HOME AND 

INFIRMARY, ETC.; MEMBER OF THE MEDICAL AND CHIRURGICAL FACULTY 

OF MARYLAND, THE AMERICAN NEUROLOGICAL ASSOCIATION, ETC. 






Ullustratefc 

PHILADELPHIA 

P. BLAKISTON, SON & CO. 

IOI2 WALNUT STREET 
1897 



e^> 





Copyright, 1897, by P. Li.akiston, Son & Co. 



Press of Wm. F. Fell & Co., 

1220-24 Sansom St., 

philadelphia. 



PREFACE. 



At this day, when the fecundity of the medical 
press is so great, it behooves an author to offer a 
reason, an excuse, or an apology for bringing forth 
a new book. In regard to this volume there are 
two reasons that may, perhaps, be deemed suffi- 
ciently weighty to warrant its appearance. The 
first of these reasons is too obvious to require 
elaboration ; namely, the importance of the subject. 
Every day in his rounds the physician meets with 
some phase of hysteria. Sometimes the diagnosis 
can be made at the threshold of the door, but at 
other times it is difficult in the extreme — a common 
disease, often a puzzling disease, always difficult to 
manage. 

The second reason is that, while there exists an 
immense amount of literature on hysteria, there is 
no recent book in English on the subject. Of 
course, it is treated of in works on general medicine, 
but rarely with the minuteness that the importance 
of the subject warrants. 

The object of this little volume is to present the 
symptomatology and differential diagnosis of hys- 
teria in as concise a manner as possible, and to in- 
dicate the various therapeutic measures that have 



iv PREFACE. 

been found useful in the treatment of this disorder. 
The general practitioner, for whom this book is 
especially intended, not only wants to know to what 
class of cases the rest cure, massage, electricity, 
etc., are applicable, but also how these important 
therapeutic measures are to be carried out. Hence 
the sections on these and other modes of treatment 
are prepared with some attention to detail. A few 
conditions are discussed which, strictly speaking, do 
not belong to hysteria, but are very closely allied to 
this neurosis. 

It was intended at first to illustrate certain phases 
of hysteria by original photographs, but these were 
found to be much inferior to, and far less typical 
than, the beautiful drawings of Richer which have 
been used. The diagrams have been taken some 
from the works of Gilles de la Tourette, others from 
Charcot. 

A large amount of literature on the subject of 
hysteria has been reviewed and references given to 
the most important publications 

The author will be more than satisfied if this little 
volume will contribute its mite toward furthering 
the work of that most important of all physicians, 
the general practitioner. 

8ig Charles Street, N. 



CONTENTS. 



Chap. Page 

I. Historical, 9 

II. The Nature of Hysteria ; Etiology and Path- 
ology, 29 

III. Symptomatology, 56 

IV. Disturbances of Motion: Tremor, Contracture, 

Paralysis, 96 

V. Convulsive Attacks : Major and Minor At- 
tacks. — Hystero-Epilepsy, 122 

VI. The Mental Condition in Hysteria, 141 

VII. Visceral and Vasomotor Disturbances, 172 

VIII. Differential Diagnosis, 204 

IX. Treatment, 221 

X. Electrotherapy. — Hydrotherapy. — Massage, . .245 

XI. The Rest Cure. — Hypnotism. — Surgical Inter- 
ference in the Treatment of Hysteria, . . . 264 

INDEX, 295 



LIST OF ILLUSTRATIONS. 



FIG. PAGE 

i. Disseminated Anesthesia (anterior and posterior views), . 67 

2. Glove and Stocking Form of Anesthesia (anterior and 

posterior views). 68 

3. Hemianesthesia, 69 

4. Normal Visual Field, 80 

5. Moderate Concentric Contraction of the Visual Field, 

with Reversal of the Red and Blue Lines, 81 

6. Hysterogenic Zones (anterior view), 92 

7. Hysterogenic Zones (posterior view), , 93 

8 "\ 

) Forms of Contracture of Hand and Wrist (after 

9 " t Richer), . 103 

11. Contracture of the Lower Extremity (after Richer), . ,105 

12. Hysterical Contracture of the Foot : Equinovarus Type 

(after Richer), 106 

13. Contracture of Foot without Contracture of the Toes 

(after Richer), 106 



FULL PAGE PLATES. 

THE CONVULSIVE ATTACK {after Richer). 

Plate I. First or Epileptoid Period, 124 

Tonic Spasm. 
Plate II. Second Period or Period of Contortions, . . .132 

Fig. 1. Movements of Wide Range. 

Fig. 2. Hysterical Opisthotonos. 
Plate III. Third Period or Period of Passionate Attitudes, 138 

Fig. 1. The Phase of Sadness. 

Fig. 2. The Phase of Toy or Exhilaration. 



HYSTERIA : 

ITS NATURE AND TREATMENT. 



CHAPTER I. 
HISTORICAL. 

The opinions and observations of men living at 
different periods of the world's history concerning 
some one subject form an interesting and often 
useful part of the study of such subject. There is 
much to be gained by thus following out the evo- 
lution of some general principle. At first sight it 
would seem a useless and empty labor to gather 
up the historical fragments of some scientific truth, 
since science has experienced such frequent and 
violent cataclysms, shaking her very foundations 
and changing completely the points of view. Yet 
even in science this retrospection is not without its 
uses. Our grasp of a subject is apt to be more 
comprehensive and the expression of our opinion 
less dogmatic if we have followed its history through 
the various phases of its development. Of all the 
branches of science, medicine has perhaps suffered 
the most sudden arid startling changes. The dis- 
covery of some new principle is revolutionary, and 
many of the observations made under the influence 

2 9 



io HYSTERIA: ITS NATURE AND TREATMENT. 

of the old principles are rendered valueless. In 
spite of this fact, however, the study of the history 
of medicine is eminently suggestive, and conse- 
quently of great value. 

A goodly volume would be required to do any- 
thing like justice to the history and literature of 
hysteria, and the sketch here given embraces only 
the barest outlines. If we consider the nature and 
frequency of hysteria, and the varied and striking 
phenomena which characterize it, we are not sur- 
prised to find it mentioned in the earliest medical 
writings. Hippocrates describes the affection in his 
' k De Yirmnibus," and makes allusions to it in his 
" Prognostics." Sydenham * quotes a letter from 
Democritus to Hippocrates relative to hysteria. 
Aretaeus,f whose date is uncertain, but who prob- 
ably lived in the latter part of the second century, 
while holding very remarkable views as to the 
etiology of hysteria, describes many of its character- 
istic symptoms. Celsus (" De Vulvae Morbo ") and 
Galen (" De Locis Affectis ") both give brief accounts 
of the disorder. 

Throughout the centuries preceding the middle 
ages we find no additions to the literature of hyste- 
ria. The science of medicine was at a low ebb, and 
the teachings of Galen prevailed with little change 
for many centuries. With the middle ages came a 
curious and interesting manifestation of hysteria. 



"* Rush's translation. 

f " De Causis et Signis Morborum. 



HISTORICAL. ii 

Previous to this time hysteria appeared only in its 
simpler forms, but during the middle ages, and, in 
fact, coming down to our own time, occurred out- 
breaks of what may be regarded as epidemic hys- 
teria. That these phenomena were not at the time 
regarded as hysterical manifestations is quite certain. 
The denseness of the superstition of the time and the 
unbridled power of priestcraft must be taken as the 
explanation both of the curious hysterical or psychic 
phenomena, and also of the failure in great part of 
the physicians of the day to recognize them as such. 
Many of these epidemics of hysteria were closely 
related to the religious notions at that time prevalent, 
either as to cause or cure, and it must be borne in 
mind that religious superstition was the most intense 
passion of the time of which we are speaking. 
Among the earliest of these hysterical epidemics was 
that curious and fantastic dancing mania known as 
the dance of Saint John. 

The following description is taken from Hecker's * 
interesting work : "In 1334 were seen in France and 
Germany bands of men and women marching hand 
in hand in the streets, dancing furiously until they 
fell prostrate. They appeared entirely insensible to 
their surroundings, shrieking out the names of saints 
and leaping high in the air. The fits often re- 
sembled epilepsy, the subjects of them falling sense- 
less, foaming at the mouth, and exhibiting grimaces 
and contortions of the body. A prominent symptom 

* " The Epidemics of the Middle Ages." Tr. Babington, 1835. 



12 HYSTERIA: ITS NATURE AND TREATMENT. 

was a marked condition of tympany, the abdomen 
being often enormously distended. If in any way 
this tympany could be relieved the fits generally 
came to an end. Many of the dancers wore belts 
into which sticks were stuck, which were twisted to 
produce compression, or some sympathetic friend 
would kick the affected person violently in the 
abdomen. This latter practice, as the old chron- 
iclers relate, caused the custom of wearing sharp- 
pointed shoes, then in vogue, to be abandoned. 
Red colors so infuriated the dancers that in some 
towns the wearing of red garments was prohibited 
by law. The populace all turned out to witness these 
processions of dancers, who were supposed to be 
possessed of demons." 

These epidemics spread with fearful rapidity, whole 
towns or cities becoming affected. The origin of the 
name, and perhaps of the dance itself, grew out of 
the orgies held upon Saint John's Day, and toward 
the close of these epidemics, that is after several 
years, these scenes took place only at or near the 
occurrence of this festival. In 141 8 Strasburg was 
visited by a dancing mania, known as the dance 
of Saint Vitus, from the fact that those affected found 
relief and cure at the shrine of this saint. Some- 
what similar to the dancing manias mentioned above 
was the dance of Saint Guy. Some time before the 
occurrence of the epidemics which have been spoken 
of, in the year 1237, at Erfurt, a violent dancing mania 
seized the children of the town, many of whom are 
reported to have died from its effects, and others to 



HISTORICAL. 13 

have had a tremor to the end of their lives. Para- 
celsus describes these epidemics, stating that in some 
persons it took the form of immoderate and uncon- 
trollable laughter, while in others it manifested itself 
in running, dancing, and other movements. In most 
of the epidemics the dancers were greatly affected 
by music, and the magistrates were accustomed to 
hire musicians to play for them, and also robust per- 
sons to dance with them until they were utterly ex- 
hausted and fell to the ground. Another epidemic 
which spread through Italy at this same epoch was 
the Tarentism. The cause of this epidemic was pop- 
ularly supposed to be the bite of the tarantula, a spe- 
cies of spider. Baglivi* gives a minute account of 
the effects supposed to be produced by the bite of 
this insect. It is somewhat significant that in speak- 
ing of the persons who inhabited the region where 
this species of spider is found, Baglivi describes them 
as "irascible, impatient, and subject to insomnia," to- 
gether with other symptoms of nervous instability. 
Hecker (loc. cit.) } in describing the symptoms of 
Tarentism, gives a fairly recognizable picture of hys- 
teria. These persons, he says, were melancholy at 
times, again laughing, and often maniacal. They 
passed large quantities of pale urine, and were 
affected with loss of voice, blindness, and vertigo. 
The theory upon which this dance was founded was 
that the poison of the spider was eliminated through 
the pores of the skin, and hence some active ex- 

* "Opera Omnia." Ed. 1788. 



14 HYSTERIA: ITS NATURE AND TREATMENT. 

ercise was necessary to promote the free action of 
the perspiration. Music had a very soothing effect 
upon these persons, and the notes of some of the 
tunes are still extant. A dance similar to the Tar- 
entism, called the Tigretier, is said to have been prac- 
tised in Abyssinia from early times.* Throughout 
the middle ages, and, in fact, coming down to mod- 
ern times, were to be seen epidemics of hysteria 
which differed more or less in their minute details, 
but conformed to the general type of hysterical dis- 
orders. These epidemics sometimes took the form of 
catalepsy or trance ; sometimes the form of more or 
less perfectly developed hystero-epilepsy. Again, 
the prominent symptoms were mental, associated 
with hallucinations and delusions. The most nota- 
ble of these epidemics occurred in, or took their ori- 
gin from, the convents. Youth, seclusion from the 
ordinary avocations of life, and the dominance of 
strong religious beliefs, amounting at this era to 
rank superstition, furnished the most favorable con- 
ditions possible for the growth and development of 
hysteria. 

A few examples will illustrate the form of hysteria 
which flourished in the convents of Europe during 
this period. In 1609, to quote Richet,*)* — to whose 
work the reader is referred for a most interesting 
and complete account of these epidemics, — there 
occurred a demoniac possession among the nuns of 

* Nathaniel Pearce, " Life and Adventures." 

f " Etudes Cliniques sur La Grande Hysterie ou Hystero-Epilepsie," 
Paris, 1885. 



HISTORICAL. 15 

St. Ursula at Aix. Some of the symptoms were 
" hallucinations, impulsive movements, a horror of 
the confessional, suicidal tendencies," etc. The usual 
form of the delusion was that of demoniac possession. 
The nuns declared that Satan entered into their 
chambers, commanding them to commit sinful and 
shameful actions and forbidding confessional. At 
Loudun, in 1632, was enacted a drama of hysteria 
terrible in its denouement. The Sister Superior de- 
clared that she had been visited at night in her cham- 
ber by the phantom of a priest of the village, Urbain 
Grandier by name. During the first visits this demon 
in human shape hinted at certain revelations of relig- 
ious secrets and religious mysteries which his power 
would reveal. Upon subsequent visits the demon 
made unholy propositions to the sister, declared his 
love for her, and overpowered her with caresses. 

Very soon, one after another of the nuns of this 
convent declared that they in like manner were 
nightly visited by the apparition of Urbain Grandier, 
and described in the most glowing and shameful 
terms the amorous expressions and lascivious actions 
of the priest. The contagion spread to the women 
of the village, who testified at the trial that Grandier 
had made improper proposals to them during con- 
fessional. An immense amount of testimony was 
taken at this trial, the nature of which might have 
put Rabelais to the blush. The unfortunate priest, 
concerning whom there had never before been a 
breath of reproach, w T as condemned to death and 
executed. 



16 HYSTERIA: ITS NATURE AND TREATMENT. 

The demoniac possession of Louviers in 1642 re- 
sembled in most respects that of Loudun. The 
unfortunate victims of this epidemic of hysteria had 
hallucinations of all the senses; they had visions of 
lighted torches, balls of fire, fantastic animals, or 
imaginary personages. Sounds of blasphemies or 
lascivious words and horrible suggestions rung in 
their ears. These subjective symptoms were often 
accompanied by convulsions, contractures, loss of 
consciousness, and the like. These young persons 
were for the most part girls of the best families, well 
educated and consecrated to a religious life. 

In the year 1491 was seen a curious epidemic of 
hysteria in a convent at Cambrai. The nuns were 
horribly tormented by demons ; those thus affected 
ran about the fields like dogs, threw themselves in 
the air in imitation of birds, climbed trees like cats, 
and hung from the branches. They made all kinds 
of queer sounds, mostly in imitation of the cries of 
animals. They also professed the power of divina- 
tion. The persons in authority, both temporal and 
spiritual, were in the habit of questioning these 
afflicted persons, and by certain exorcisms extorted 
confessions from them, which confessions were be- 
lieved to be the veritable words of the Evil One. In 
the epidemic just spoken of the devil, in the form of 
one of the afflicted nuns, confessed that he had 
obtained admission into the convent by the aid of one 
of the sisters who had submitted to his embraces in 
the cloisters. The demons were exorcised by send- 
ing the names of the persons possessed to Rome, 



HISTORICAL. 17 

where they were read out at mass by the Pope him- 
self. 

Throughout the latter part of the fifteenth and 
early part of the sixteenth centuries occurred curious 
epidemics of demon worship. These took various 
forms and showed themselves, now as epidemics, 
now in isolated cases. The general features, either 
in the case of the epidemic or isolated form, were 
substantially the same. There was supposed to be 
a compact with the devil, formed in some mysteri- 
ous way, and this compact required implicit obedi- 
ence to the Satanic will. Many horrible instances 
of infant murder and anthropophagism are related 
by the old chroniclers. The civil authorities, stimu- 
lated by the priests, were eager in hunting out these 
demoniacs and putting them to death. 

It is a very suggestive fact that sexual perversion 
played a prominent part in these demoniac posses- 
sions. Women declared under oath that they had 
visited the midnight orgies of the demons and witches 
and had been violated by demons. They described 
in disgusting detail and with shocking minuteness 
the sexual organs of the devil and his peculiar modes 
of cohabitation. One of the old writers naively 
remarks that fortunately this intercourse was never 
fruitful. In 1550 the nuns of the convent of Uvertet 
were seized with epidemic hysteria. The attacks 
began with hallucinations of various kinds. Thev 
declared that they were awakened by feeling them- 
selves being drawn out of bed by the feet, and when 
they reached the floor the most violent convulsions 



18 HYSTERIA: ITS NATURE AND TREATMENT. 

would come on, so violent that the persons about 
them had great difficulty in restraining them ; pale 
urine was voided in enormous quantities. One very 
curious hallucination which characterized this epi- 
demic was the sensation of being tickled on the soles 
of the feet, and this caused immoderate and uncon- 
trollable laughter. A very harmless lady living in 
the neighborhood was, for no reason, supposed to be 
in league with the devil and the cause of this posses- 
sion. The torture was applied to her, resulting, as 
it often did, in death. This epidemic lasted about 
three years, and it is curious to note that at the time 
of the subsidence of the epidemic, or, rather, imme- 
diately before its subsidence, it was thought best to 
refuse the public admission to the convent. It was 
the custom for large numbers of persons to go to the 
convent to witness the supposed manifestations of 
the devil, and the power of religion in overcoming the 
Evil One. Just as soon as the public were excluded 
the epidemic came to an abrupt conclusion. It is 
also curious to note that this coincidence attracted 
no attention, not even from the medical men, so 
absolute was the power of religious dogmas, so dense 
was the superstition of that period. 

The nuns of St. Brigette were attacked with a 
similar affection ; they imitated the cries of animals, 
and were frequently seized with a constriction of the 
throat, so severe as to prevent their taking food. 
The first one of the inmates of the convent to be 
affected was a young girl who took the veil on ac- 
count of an unfortunate love affair. This epidemic 



HISTORICAL. 19 

lasted ten years. The epidemic which took posses- 
sion of the nuns of Kintorp, near Strasburg, was at 
first attributed to epilepsy. The persons affected 
fell to the £round, lost consciousness, bit and tore 
their clothing. As soon as one was seized it was a 
signal for the rest who were in the same apartment. 
They complained of a burning sensation in the soles 
of the feet, likening it to contact with boiling water. 
Here, as elsewhere, innocent persons were accused 
of being in league with the devil and causing the 
attacks. The cook of the convent and her mother 
were convicted and burned at the stake. The epi- 
demic of the nuns of the convent of Nazareth at 
Cologne, in 1560, was notable for the prominent 
part played by sexual hallucinations, the nuns de- 
claring that the demons came into their beds at night. 
At Amsterdam, in 1566, there appeared an epidemic 
of hysteria, similar to the epidemics that have been 
described, in an orphan asylum, the inmates being 
mostly boys. This epidemic was characterized by 
convulsive seizures, vomiting of foreign substances, 
such as nails, needles, bits of thread, wool, etc. 
There was noted in this epidemic a feature which 
was very common in the later epidemics, namely, 
the use of apparently unknown languages. Boys, 
who were not supposed to be acquainted with any 
other language than their own, spoke Latin or Greek 
with apparent fluency. This was the first epidemic 
of this kind among males, all the others before al- 
luded to being confined to the opposite sex. In the 
province of Lorraine, in the space of fifteen years, 



20 HYSTERIA: ITS NATURE AND TREATMENT. 

Remy, who was the public prosecutor, caused to be 
put to death no less than 900 persons accused of 
being devil worshipers. 

To show that epidemic hysteria was not confined 
to Southern nations, the epidemic of Elfdalem, in 
Sweden, may be mentioned. Bekker, quoted by Cal- 
meil,* describes this epidemic, which did not differ 
materially from those of France and Italy, except so 
far as the imagination of the North lacks the tropi- 
cal luxuriance of the South. The details of the epi- 
demic of Sweden necessarily differed somewhat from 
that of the Southern races, since the surroundings, 
the religion, and, above all, the mythology or super- 
stition of the people, differs so greatly. The tribunal 
which was appointed by the king of Sweden to take 
action upon this supposed demoniac possession, con- 
demned to death more than 80 persons and punished 
more lightly a large number of others. This was very 
heroic treatment, but in this particular instance was 
effective. In many other instances, perhaps we 
may say generally, rigorous persecution rather aug- 
mented than caused any abatement in the hysterical 
fury. 

The practice of flagellation, f which began as a re- 
ligious observance and can be traced to very early 
times, became, in the middle ages, a veritable hys- 
terical epidemic. In 1260, through the influence of 
a monk named Rainer, an epidemic of flagellation 



*"De la Folic" 

f " Encyl. Brittan.," vol. IX. 



HISTORICAL. 21 

spread through Italy, and thence through a large 
part of Europe. Vast crowds of men, women, and 
children, from every rank of society, marched 
through the country, furiously lashing themselves 
with leathern thongs. Pilgrimages were started, 
every village or city visited contributing its quota. 
So furious were these epidemics that edicts, both 
secular and religious, were issued against them. 
Many of the Crusades, especially the Children's Cru- 
sade, might, without doing violence to our subject, 
be ranked as hysterical manifestations. Certain it is 
that hysteria played a very prominent part in these 
uncontrollable relioious movements. 

The hysterical phenomenon of stigmatization, or 
the appearance of wounds in the hands, feet, and side, 
resembling more or less closely the description given 
in the Scriptures of the wounds of Christ, have been 
made the subject of careful study, both from a scien- 
tific as well as from a theological standpoint. Cases 
of stigmatization are frequent, both in early and late 
literature. A very interesting review of this subject, 
by the Rev. Richard Wheatley,* traces the phenom- 
enon from its earliest authentic instances down to 
modern times. Among the first stigmatists was St. 
Francis d'Assisi, in Italy, in 1224. This saint prayed 
that he might be allowed to suffer crucifixion like 
Christ, and immediately after one of his fervent 
prayers his feet, hands, and side showed the charac- 
teristic bleeding wounds. Christine de Stumbele, 

* Popular Science Monthly, vol. XXXIII. 



22 HYSTERIA: ITS NATURE AND TREATMENT. 

in 1242, Veronica Giulani, in 1727, Catherin Em- 
merich, in 181 1, Pal ma d' Oria, in 1 87 1, are among 
the notable examples. One of the latest cases, and 
one that was carefully observed, is that of Louise 
Lateau, in Belgium. This case attracted great at- 
tention, and has been so often described that it is 
too well known to make any reference to it. The 
cases mentioned are only the most notable ones, 
since the religious records show more than 100. 
While a few of these cases were evidences of pur- 
pura hemorrhagica, or some similar affection, the 
great majority were the grossest forms of deception, 
encouraged often by overzealous priests, and ac- 
cepted by a people sunk in crass superstition. 

The vampirism of Poland and Hungary, in 1740, 
was a wide-spread hallucination that certain specters 
came at night and sucked the blood. This supersti- 
tion is, of course, very ancient, and can be found in 
the folk-lore of almost all peoples, but in the two 
countries mentioned, and at the time alluded to, the 
superstition amounted almost to an epidemic of 
hysteria. 

In the history of our own country we would not 
expect to find records of wide-spread epidemics of 
hysteria. At the time of the first settlement of 
America the progress of civilization had materially 
lessened this form of hysteria ; superstition was not 
as rank, the power and influence of religion not as 
undisputed. Added to this, the country was very 
sparsely settled for so many decades, thus allowing 
little social intercourse, and the character of the 



HISTORICAL. 23 

early settlers, together with their active mode of life, 
was by no means that which favored the develop- 
ment of epidemic hysteria. Although the epidemfc 
form of hysteria was not often seen, the minds of 
the people were imbued with a belief in the miracu- 
lous, and this took the form of a demoniac posses- 
sion, or, in other words, witchcraft. That many of 
the unfortunate persons burnt as witches were en- 
tirely innocent of any belief in witchcraft is certain, 
but a large number of the accused not only believed 
in the diabolic possession, the compact with the 
devil, the power to cast spells and to foretell the 
future, in short, to act as the special agent of His 
Satanic Majesty, but they sealed their belief with 
their blood. These persons were unquestionably 
hysterics ; the convulsions, the hallucinations, the 
well-known anesthetic condition of their bodies, all 
these recorded facts point unmistakably to hysteria. 
In regard to this latter symptom, the test for witches, 
or, as they were called on the continent of Europe 
during the middle ages, persons possessed of the 
devil, was made by blindfolding the accused one 
and with a needle ascertaining whether there were 
any spots on the body where the skin could be 
pierced without causing any evidence of sensation ; 
this, by the way, being a very commonly resorted to 
test for hysteria to-day. Dr. Andrew D. White, 
in his " New Chapters in the Warfare of Science," 
says in regard to the witchcraft and like hysterical 
phenomena of puritan New England : 

"The life of the early colonists in New England 



24 HYSTERIA : ITS NATURE AND TREATMENT. 

was such as to give rapid growth to the germs of 
the doctrine of possession brought from the mother 
country. Surrounded by the dark pine forests, hav- 
ing as their neiehbors Indians, who were more than 
suspected of being children of Satan, harassed by 
wild beasts apparently sent by the powers of evil to 
torment the elect, with no varied literature to while 
away the long winter evenings, with few amusements 
save neighborhood- quarrels, dwelling intently on 
every text of Scripture which supported their gloomy 
theology, and adopting its most literal interpretation, 
it is not strange that ideas regarding the darker side 
of nature were rapidly developed." 

More closely akin to epidemic hysteria, in fact a 
distinct phase of it, were the orgies enacted at the 
religious revivals of Kentucky and Tennessee in the 
early part of this century. Dr. Felix Robertson * 
gives a very interesting account of one of these 
early "revivals" in Tennessee in the year 1803. 
The ecstatic state, or as we would undoubtedly call 
it now hysterical state, into which so many persons 
passed, was regarded as- a favorable visitation of the 
Deity, as a special gift of the Spirit. The ages of 
those affected varied from six to sixty, but by far the 
greater number affected were young women. The 
paroxysm continued for an hour or more, and con- 
sisted of violent trembling and shaking, accompanied 
with loud groans and cries. At other times there 
would be "jerks," — sudden inclinations of the head 

* Phila. Med. and Phys. Journal, vol. II, 1805. 



HISTORICAL. 25 

continuing for a quarter of an hour or longer. 
Sometimes the affected person would leap high in 
the air or run violently and aimlessly until exhausted. 
Other symptoms were dancing, singing, labored res- 
piration, lethargy, etc. Anesthesia was very gen- 
erally present and excited much comment. Yandell * 
gives a graphic account of similar epidemics in Ken- 
tucky about the same period. 

At one meeting it was computed that no less than 
3000 persons fell to the ground in convulsions. A 
quotation from Dr. Davidson shows how wide-spread 
the epidemic was, resembling in this respect some of 
those of the middle ages. The same author paints 
in striking language the impressive scenes enacted 
at these early and primitive religious gatherings: 
" The glare of the camp fires falling on a dense 
assemblage of heads simultaneously bowed in prayer, 
hundreds of candles suspended from the trees, the 
solemn chanting of hymns, the impassioned exhor- 
tations, the sobs, shrieks, or shouts, the sudden 
spasms which seized upon scores and dashed them 
to the ground, all conspired .not only to invest the 
scene with terrific interest, but to work up to the 
highest pitch of excitement the feelings of all pres- 
ent." Granade, a celebrated exhorter, says that at 
one of his meetings "the people fell as if slain by a 
mighty weapon, and lay in such piles and heaps that 
it was feared they would suffocate, and that in the 
woods." Catalepsy, convulsions, mimicry of ani- 

* " Brain," vol. IV. 



26 HYSTERIA: ITS NATURE AND TREATMENT. 

mals, a peculiar laugh, called the " holy laugh," were 
some of the most notable symptoms. 

Epidemics of hysteria have often been observed 
among the North American Indians, the most strik- 
ing examples, perhaps, being the "ghost dance," 
the " Messiah dance," etc., which have been described 
in some of the late magazines. 

Hysteria plays a very important part in the " camp 
meetings " and "revivals " of the negroes. A former 
student of mine, Dr. S. W. Welch, of Alabama, has 
kindly given me some instances that have fallen 
under his observation, of hysteria in the negro. 
The " camp meetings " usually lasted for two weeks 
or longer, being terminated by the commencement 
of the cotton picking. Besides the usual shouting, 
dancing, singing, and such-like performances, there 
appeared an epidemic of catalepsy, or, as the ne- 
groes called it, " trance." 

After recovering from this " trance " wonderful 
accounts were given of the things seen and heard. 
One example will sufficiently illustrate the vividness 
of the negro imagination. A negro girl about six- 
teen years of age, after awakening from a "trance," 
told Dr. Welch that she had walked a two-inch plank 
over the abyss of hell. Below she saw the blue 
flames, and the "Old Boy" piling fuel around the 
sinners' heads. Conspicuous among these latter was 
the figure of a gentleman of the community, who had 
recently died, and who was noted for his profanity 
and cruelty to the negroes. She made a safe escape, 
although the devil reached after her and was so 



HISTORICAL. 



27 



close that she could see his Ion or claws. She then 
found herself in a golden street, and in the distance 
saw God sitting upon a white throne, with Jesus on 
His right hand and " Old Miss Jesus " on His left. 
Upon being interrogated as to what " Miss Jesus " 
looked like, she replied that " Miss Jesus " had long 
white hair like "Old Miss" (a saintly old lady who 
had formerly owned the girl). 

It is very interesting to compare such accounts as 
this with the hysterical visions of the middle ages. 

Apart from these wild outbursts of epidemic hys- 
teria of which we have been speaking — -this accentu- 
ation of the hysterical state — we find frequent and 
important mention in the literature of the ages past 
of the milder forms of the malady. We find certain 
diseases, such, for example, as blindness, deafness, 
paralysis, and the like, cured by the laying on of 
bands of the Irishman, Greatrakes, or by a pilgrim- 
age to a famous shrine, such as the tomb of Francois, 
the " diacre Paris." The kind's touch and the won- 
derful cures wrought by it, not only of the king's 
evil, but of diverse diseases, all of which bear a 
close resemblance to hysterical symptoms, show us 
how common such conditions were. The method 
employed, and the instantaneousness of the cure, 
according to the old chronicles, fully warrant us in 
regard in o- these so-called diseases as evidences of 
hysteria. 

This brief historical retrospect shows us that from 
the earliest times of which we have any authentic 
records, physicians have been familiar with the main 



28 HYSTERIA : ITS NATURE AND TREATMENT. 

phenomena of hysteria, however fantastic may have 
been their ideas respecting its cause. Again, we ob- 
serve the causative influence of great passions, such 
as religious superstition, fear, licentiousness, and the 
like. The contagiousness of hysteria and its mimi- 
cry are well illustrated by the epidemics of the middle 
ages, and also by the later epidemics to which refer- 
ence has been made. While the more violent mani- 
festations of hysteria, such as the dancing manias, 
have hardly survived to the present day, we are 
forced to the conclusion that the malady in its other 
forms has increased rather than diminished. To 
prove this it would only be necessary to bring our 
historical sketch down to the present time and include 
modern spiritualism, faith cure, mind cure, nervous 
prostration, often falsely so-called, much of what is 
designated neurasthenia or hypochondria, together 
with those multiform hysterical symptoms which are 
embraced under the comprehensive term, nervous- 
ness. 



CHAPTER II. 

THE NATURE OF HYSTERIA; ETIOLOGY 
AND PATHOLOGY. 

In considering the nature of a subject like hysteria, 
which cannot be said to have anything but a mere 
hypothetical pathology, it is well to consider care- 
fully the etiology, hoping thus to get some light on 
the subject. With a clear notion of the etiology of 
hysteria we are in a better position, of course, to 
look for pathological lesions, and in this way narrow 
down our researches. The first question in the 
etiology of hysteria is the influence of sex as a pre- 
disposing cause. With the ancients, holding the 
Hippocratic or Galenic theories, this was no ques- 
tion, since from their definition hysteria could be 
present only in the female. The late General 
Butler is said to have used this argument with ereat 
effect in the trial of a certain case in which it was 
alleged that his client was hysterical. " Does not 
the word hysteria mean womb? " he asked of the 
medical witness who had testified as to the hysteria 
of his client. Of course the doctor had to admit 
that it did. " Well," said Butler, " I had this man 
carefullv examined before coming- into court, and he 
has no womb." During the middle ages we find 
epidemics of hysteria affecting males as well as 

females, but the hysterical nature of the epidemic 

29 



30 HYSTERIA: ITS NATURE AND TREATMENT. 

was overlooked, or, rather, the religious superstition 
of the times regarded these epidemics as veritable 
possessions of the devil. One of the earliest writers 
to recognize the fact that hysteria could occur in the 
male was Sydenham.* " Few women," he says, 
" excepting such as work hard and fare badly, are 
quite free from every species of this disorder, and 
several men also, who lead sedentary lives and study 
hard, are affected with the same." Briquet f rather 
underestimates the frequency with which hysteria is 
met with in men when he puts the proportion as i 
to 20. Much depends upon the comprehensiveness 
of the term "hysteria," but if we include certain 
mental manifestations of hysteria, the disproportion 
between the two sexes will not be found to be as 
great as that stated above. The faulty conception 
of the nature of hysteria led the older writers to 
call this condition, when met with in the male, hypo- 
chondria, and this error has vitiated statistics ever 
since. The two states are similar and often exist 
coincidentally, but fundamentally they are distinct. 
No statistics are necessary to prove the fact that 
hysteria is most frequently seen near puberty; that 
is, between the ages of fifteen and twenty, though 
no age is exempt. It may be occasionally observed 
in quite young children, though one is sometimes 
inclined to doubt the accuracy of the diagnosis of 
infantile hysteria. While not, perhaps, very common, 

* Rush's translation. 

| " Traite Clinique et Therapeutique de l'Hysterie," Paris, 1859, 



THE NATURE, ETIOLOGY, AND PATHOLOGY. 31 

it is not rare to find marked hysteria in the aged. 
Hippocrates and Galen were inclined to the belief 
that hysteria was more common after puberty because 
the womb became lighter, and Aretaeus * explained 
the fact of the rarity of hysteria in old women by 
stating that in old age the womb was bound down 
and therefore could not travel through the body, 
this being, as we shall see, the Hippocratic idea of 
the causation of the affection. 
>^-In connection with the question of age, the influ- 
ence of climate and race must be considered, since 
these latter factors are important in determining the 
period of puberty and the rapidity of mental de- 
velopment. While hysteria is common in cold coun- 
tries, Russia, Lapland, etc., its most congenial soil is 
the warm latitudes. The emotional nature, the im- 
pressionability, the intensity of the passions, the 
demonstrativeness, the responsiveness of the South- 
ern peoples comprise a temperament much more 
suited to the development of hysteria than the un- 
demonstrative, stolid, sluggish inhabitant of Arctic 
regions. To what extent this difference is climatic, 
and to what extent racial, is hard to decide, for we 
cannot say just how great has been the influence of 
the warmth and brightness upon the race character, 
i^ er tain forms of hysteria are very common among 
the^fcgroes. Largely endowed with superstition, 
their hysterical manifestations are closely related to 
their religious extravagances. Afifegro camp meet- 

* Translated by Reynolds. London, 1837. 



32 HYSTERIA: ITS NATURE AND TREATMENT. 

ing in a locality where the restraining influences and 
the imitation of a higher civilization have not deeply 
penetrated, will furnish material f©r a description of 
many of the phases of hysteria.' I have not met 
with paralysis of motion or sensation, or long con- 
tinued contractures as frequently among thel/egroes 
as in the white race. But convulsive seizures, and 
more or less completely developed major attacks 
are very common, as are paresthesia and mental 
hysteria. I am inclined to believe that hysteria is 
more frequent in this race to-day than it was dur- 
ing the slavery period. The occurrence of hysteria 
among the Indians has been referred to. In the 
evolution of a race from barbarism to civilization 
there is, of course, a corresponding change in the 
nature of the mental derangements. The wilder fea- 
tures of the contagious hysteria of the uncivilized 
become less and less frequent, and in their place are 
seen the less obtrusive forms, particularly the purely 
mental form.^ 1 ^ 

The subject of the influence of race upon the de- 
velopment of hysteria is a very wide one, and its 
proper place can be assigned to it only when we have 
at our command more accurate and exhaustive sta- 
tistics than are at present available. 

The question of heredity plays an important role 
as a causative factor in hysteria, as it does in all the 
neuroses. Briquet's oft-quoted statistics are not 
necessary to convince any one who has been an ob- 
server of hysterical families of the truth of this state- 
ment. As in the case of other neuroses, the here- 



THE NATURE, ETIOLOGY, AND PATHOLOGY. 33 

dity need not of necessity be direct, that is, a trans- 
mission of hysteria itself from parent to child, but 
most frequently is indirect, in that the antecedent of 
hysteria may be any form of neurosis or mental dis- 
ease. The inheritance of that indescribable some- 
thing which we call a neurotic temperament, an 
unstable, badly organized, or imperfectly developed 
nervous system, while of uncertain definition, is a 
most potent factor in the subsequent life-history of 
the unfortunate legatee. While noting the impor- 
tance of heredity, we should be careful not to as- 
cribe to it evil results which really come from bad 
environment. This latter point will be considered 
under the effects of education. 

Some authors have claimed that certain diatheses 
were favorable to the development of hysteria. Gras- 
set has laid especial stress upon the tubercular dia- 
thesis in its relation to hysteria, claiming that it exerts 
a distinct influence in the production of the neurosis. 
Rheumatism and gout have also been assigned a 
certain place in the general predisposition toward 
hysteria. Any slow or long continued disease must 
necessarily exhaust the nerve centers, for the mental 
effect of severe disease, the fear of death and the 
anxiety consequent upon it, play their part, as well 
as the nutritive changes which are the direct results 
of the pathological processes. Further than this 
there has never seemed to me to be any predispos- 
ing effects traceable to any disease, though the com- 
bined effects referred to above may be noted after 
or during the course of most serious illnesses. 



34 HYSTERIA: ITS NATURE AND TREATMENT. 

The association of hysteria with organic cord or 
brain disease, is very often seen, and it is a difficult 
matter to ascertain the exact causal relation which 
exists between them. 

The mistake is often made of attributing to hered- 
ity the effects, good or bad, of education and en- 
vironment. Educational influences in the produc- 
tion of hysteria appear at both ends of the scale. 
Defective or imperfect education does not dislodge 
superstition, which, as we have seen, is very favorable 
to the development of hysteria. More than this, 
certain systems of education, while not exactly de- 
fective, are certainly very unwise, cultivating to too 
great a degree the emotional side of the child's na- 
ture ; developing the dramatic, the pathetic, the senti- 
mental, or the sensational. There are undoubtedly 
many dull minds that are quickened by this method, 
but there are many more stimulated to the point 
where the normal exhibition of the emotions stops 
and hysteria begins. As Tissot puts it, "If your 
daughter reads novels at fifteen she will have hysteria 
at twenty." While we can safely say that an imperfect 
education predisposes to hysteria, it is no less true 
that a too rigorous attention to books, with little 
or no diversion, in like manner, though to a much less 
degree, has the same tendency. The forcing sys- 
tem in vogue at some of our schools often adds hys- 
teria to the list of accomplishments. While "all work 
and no play makes Jack a dull boy," it is also very apt 
to make Jack an hysterical boy, and the same system 
is even worse for Jack's sister. There are few uni- 



THE NATURE, ETIOLOGY, AND PATHOLOGY. 35 

versities that do not show in their faculties fairly typ- 
ical examples of hysteria, the result of hard study and 
too one-sided a mode of life. 

Hardly separable from educational influences are 
the impressions of environment. The mode of 
thought and expression, the affections, emotions, 
sentiments of the child are greatly dependent upon 
the parent or teacher. The every-day life of the 
child, its general management, its associates, all 
have a distinct bearing upon its emotional nature, 
and consequently upon the tendency for or against 
hysteria. 

In addition to the predisposinginfluence of improper 
emotional environment in the formative period of 
life, there is the effect of emotion as a direct exciting 
cause. Far too little attention has been paid to this 
most important factor. The conviction has been 
growing upon me for years that in nearly every 
case of hysteria there is some distinct emotional 
cause recognized by the patient. In young girls it is 
some love affair that has not " run smooth ; " a real 
or fancied slight by the mother, uncongenial rela- 
tives, ungratified ambitions, and the like. In older 
women the causes are generally more grave. In 
most instances the reply to the question as to 
whether or not the hysterical condition was brought 
about by trouble will be in the affirmative. The 
variety of emotional causes is infinite ; a husband 
who is not kind or who is a drunkard, grief from 
the loss of children, uncongenial marriages, worry 
induced by straitened circumstances, the res an- 






36 HYSTERIA: ITS NATURE AND TREATMENT. 

gusta domi, long-continued anxiety about the health 
of some member of the family, these are some of 
the many causes that are so often responsible for 
the hysterical attack. Some one of these conditions 
appearing suddenly and in an intense form induces 
an acute attack of hysteria, or, again, when long 
continued but of less intensity, strongly predisposes 
to hysteria. The importance of bringing out clearly 
these emotional etiological factors becomes very 
apparent in the treatment of the case. It is impos- 
sible to treat a case of hysteria successfully unless 
there is perfect confidence between doctor and 
patient, and the latter will feel, and rightly so, that 
the physician does not clearly understand her case 
if he is not aware of what she thinks is responsible 
for the disease. 

In regard to social conditions, hysteria is certainly 
more common among the higher classes of society. 
It is met with, of course, in every walk of life, but 
the luxurious and wealthy classes, young persons 
who have been raised in luxury and too often in 
idleness, who have never been called upon to face 
the hardships of life, who have never accustomed 
themselves to self-denial, who have abundant time 
and opportunity to cultivate the emotional and sensu- 
ous, to indulge the sentimental side of life, whose 
life purpose is too often an indefinite and self-indul- 
gent idea of pleasure, the jeunesse doree of so- 
ciety, these are the most frequent victims of hys- 
teria. It is not the graver, but the milder forms of 
the disease that we most often see in this class 



THE NATURE, ETIOLOGY, AND PATHOLOGY. 37 

of society ; particularly the purely mental forms. 
The next most frequently affected grade of society 
is the very lowest stratum, id les extremes se touch- 
ent. In this class we find in like manner a life 
given over to enjoyment, without fixed purpose ; free 
rein given to " passions of the baser sort," not 
feeling the necessity of self-control because they 
have to a pitiably small degree any sense of pro- 
priety or decency. Between these extremes we see 
hysteria most often in persons who lead a seden- 
tary life, to which is added severe mental labor, 
care, anxiety, responsibility, monotony, and the like. 
Consequently, we see hysteria frequently among 
literary workers, teachers, clerks, etc. 

Undue excitement and public notice or publicity 
will account for the prevalence of hysteria among 
members of the dramatic profession, musicians, and 
even public speakers. 

It is a very difficult matter to assign a proper place 
to reflex irritation as a factor in the production of 
hysteria. That reflex irritation does aggravate or 
even originate hysteria in persons already predis- 
posed to it is certain. The question, and it is one of 
great importance, is whether long-continued irrita- 
tion does not induce a certain condition in the nerve 
centers, either higher or lower, even in persons not 
predisposed to hysteria, which eventually induces the 
disease. We are familiar with the profound func- 
tional alterations produced in the central nervous sys- 
tem by some very trivial peripheral irritation, showing 
a wonderful disproportion between cause and effect. 



38 HYSTERIA : ITS NATURE AND TREATMENT. 

Familiar examples are the convulsions of infancy 
from gastro-intestinal irritation, epileptiform seizures 
dependent upon a tight prepuce or eye strain, and 
the like. If we can have such wide-spread discharge 
of nerve force from such apparently slight causes, it 
is reasonable to suppose that some peripheral irrita- 
tion acting for a long time eventually establishes an 
instability of centers, higher or lower. Of course the 
whole peripheral nervous system must be included 
as presenting possible sources of irritation. Un- 
doubtedly the part of the peripheral nervous system 
which, from a priori reasoning, we should expect to 
be most responsible is that supplying the reproductive 
organs. The external genital organs are richly sup- 
plied with sensory nerves, and, as has been recently 
shown, the ovary also has a very rich nerve plexus, 
a point formerly denied. Moreover, there is no 
other reflex so frequently, so easily, and so power- 
fully stimulated by purely psychic influences. Be- 
sides this, there is a certain curiosity, often morbid, 
but perhaps always present to some degree, attached 
to the mysterious subject of generation, and conse- 
quently to the organs which subserve this function. 
It is not to be wondered at then that during certain 
critical periods when the reproductive functions play 
a prominent part, as puberty, the climacteric, preg- 
nancy, or even at the ordinary menstrual periods, 
the reflex disturbances originating from these organs 
are pronounced. Yet it is doubtful whether in the 
normal healthy subject this reflex ever passes the 
physiological limit, as it so often does in the hys- 



THE NATURE, ETIOLOGY, AND PATHOLOGY. 39 

terical subject. It is even difficult to say to what 
extent actual disease of the reproductive organs is a 
factor in the production of hysteria. It is necessary 
to discount most carefully the psychic influence pro- 
duced by disease or supposed disease of these organs. 
The very fact of the monthly period, and the 
greater or less inconvenience attending menstruation, 
acts as a constant suggestion, and the undue promi- 
nence that has been given to minor and unimportant 
uterine disorders during the last decad, has made 
it an easy and natural thing for women to refer half 
their ills to some fancied derangement of the repro- 
ductive organs. That continued disease or irritation 
of the reproductive organs may predispose to hys- 
teria is undoubtedly true, but in the vast majority of 
cases the hysterical subject refers the central disturb- 
ance to that part of the periphery which is most 
closely related to the higher centers. The impulses 
travel back along - the most familiar and most fre- 
quented paths. There exists, then, no actual rela- 
tionship between hysteria and disease of the repro- 
ductive organs. The hysterical woman refers to the 
reproductive organs as the origin of her malady 
simply because she must refer to some cause, and 
these organs are constantly suggestive. The fre- 
quency with which hysteria is seen at certain critical 
periods when the reproductive organs are under- 
going important changes — puberty and the meno- 
pause — is to be explained rather on the ground 
of the general disturbance of the nervous system 
than by any reflex irritation. We see at these 



40 HYSTERIA: ITS NATURE AND TREATMENT. 

periods a tendency to the development, not only of 
other mental diseases, but also of other maladies 
having- no connection with the nervous system. Not 
only is the nervous system perturbed by these im- 
portant crises, but the whole body is more or less 
affected by them. 

While we should be very careful in accepting any 
subjective symptoms in hysterical patients, we should 
be doubly careful when these symptoms are referred 
to the reproductive organs, for not only is it rare to 
find these organs seriously diseased in hysteria, but 
a simple examination will often fix a suggestion 
which may be difficult to dislodge. 

The ancients, as is well-known, had very pro- 
nounced views on the subject of the relationship ex- 
isting between the uterus and hysteria, regarding 
this organ as the fans et origo of the disease. Not 
only was disease of the reproductive organs sup- 
posed to cause hysteria, but there was a wide-spread 
belief among the older authors that continence was 
an important and frequent cause. 

Among other sources of peripheral irritation may 
be mentioned disorders of the gastro-intestinal 
tract. It is often a matter of difficulty to say to 
what extent this may be cause, and to what extent 
effect. The hysterical individual is very generally 
inclined to be capricious in the matter of food, and 
is very commonly more or less dyspeptic. As we 
see melancholia caused sometimes by impacted feces, 
it is not improbable that long-continued digestive 
disturbances may, to some extent, act as a predis- 



THE NATURE, ETIOLOGY, AND PATHOLOGY. 41 

posing cause of hysteria. Cullen especially, of the 
older writers, lays stress on gastro-intestinal disor- 
ders in their relation to hysteria. 

Having thus considered briefly the etiology of 
hysteria, we are in a better position to draw certain 
conclusions regarding its probable nature. As has 
been noted in the historical sketch of hysteria, the 
literature upon this subject is enormous, and the 
views held concerning the nature of the disease very 
various. The older writers seemed to enjoy elucidat- 
ing (as they thought) the mystery of the nature of 
hysteria, and in every generation almost, from the 
earliest times, some physician or philosopher seemed 
to feel himself called upon to expound his particular 
theory. Hippocrates * clearly enunciated the theory 
that hysteria was due to the movements of the uterus. 
This organ was supposed to be freely movable, and 
under certain conditions would rush upward, pushing 
the thoracic viscera into the throat and causing the 
sensation of choking. The hysterical symptoms af- 
fecting other parts of the body were in like manner 
explained on the theory of the wandering of the 
uterus. 

Briquet gives the following quotation from Plato, 
which illustrates very well the ideas of the ancients 
regarding the uterus : " The womb is an animal that 
ardently desires to beget children. When it remains 
sterile long after puberty it can scarcely tolerate this 
condition ; it becomes indignant, runs here and 

* " Complete Works." Adams. 



42 HYSTERIA: ITS NATURE AND TREATMENT. 

there through the body, arresting respiration, throw- 
ing the body into extreme dangers, and occasioning 
diverse diseases, until desire and love, uniting man 
and woman, cause to grow a f r u it as on a tree, sow- 
ing- in the womb, as in a field, invisible animals, 
nourishing them after the separation, developing 
them and giving birth to them, and in this manner 
completing the generation of animals. Thus are 
formed women and all females." Democritus, in a 
letter to Hippocrates, says : " The womb is the origin 
of 600 evils and innumerable calamities." 

Aretaeus, who lived probably in the second cen- 
tury, held the same ideas of the wandering of the 
womb that had been announced by Hippocrates. 
He states that if the womb were suddenly carried up- 
ward there would occur a choking as in epilepsy, but 
without spasms, the limbs moving irregularly, with 
loss of speech and impairment or loss of sensation. 
He explained the more frequent occurrence of hys- 
teria in the young by the assumed fact that in old 
women the womb became more tightly bound down, 
and hence was not as free to wander at will through 
the body. Celsus made no improvement upon the 
views of Hippocrates, calling the disease passio 
hysterica. Galen made the important announce- 
ment that the uterus was stationary and had no 
power of locomotion, thus upsetting the Hippocratic 
theory. He thought that the menstrual blood be- 
came dammed up in the uterus and underwent, at 
times, putrefactive changes. Galen, or at least the 
Galenic school, believed in a female seminal fluid, 



THE NATURE, ETIOLOGY, AND PATHOLOGY. 43 

and imagined that the retention of this fluid in the 
uterus was a potent cause of hysteria. A modifica- 
tion of this view was that there was an excessive 
discharge of this fluid. Aetius accepted this theory 
with the modification that malignant vapors started 
from the uterus, which view was also held by Paulus 
/Eginita. xAJexander de Tralles went back to the 
Hippocratic theory of the wandering of the uterus. 
Avicenna, who represents the Arabian school of 
medicine, adopted the theories of Galen upon this 
as upon most subjects. Forestius was such a warm 
advocate of the theory of the retention of the female 
seminal fluid that he advocated coitus as a means of 
cure whenever this remedy was allowable, and when 
not he advised the attending physician to anoint 
his finger with an ointment of musk and bring on an 
orgasm. To his credit be it said, that he recom- 
mended that this procedure had better be carried out 
by women. The views announced first by Hippoc- 
rates, and more or less modified by Galen and others, 
prevailed in the main down to the time of Charles 
Lepois, 1620. This author denied the dependence 
of hysteria upon the uterus, and described cases of 
the disease occurring in men. He believed that the 
seat of hysteria was in the brain, and drew an analogy 
between it and epilepsy. Van Helmont (1650) re- 
turned to the theory of Galen, and this theory, with 
its "humoral" modifications, was more or less 
closely adhered to by such men as Primrose (1650), 
Sylvius (1660), Etmiiller (1660), Purcell (1707), 
Pitcairne (1701), Schact (1747), and many others of 



44 HYSTERIA: ITS NATURE AND TREATMENT. 

this period. Hochstetter, in 1660, tried to prove 
that hysteria was a convulsive malady starting from 
the brain, and we find Thomas Willis (1660) ad- 
vocating this same view. Highmore, in 1661, 
agreed in the main points with this theory, but would 
not admit the brain as the seat of the disease, holding 
that hysteria was a disease of the whole system. 
Sydenham, who gives an excellent description of 
the symptoms of hysteria, believed that the animal 
spirits rushed upward and affected the nervous sys- 
tem generally. 

Morgagni believed in the uterus as the starting- 
point of hysteria. He held that an irritating in- 
fluence originated in this organ and was carried 
thence by the nerves to the brain. He gives a 
very interesting account of autopsies made by 
him in which he searched diligently for some defi- 
nite pathological lesion. He found in some of his 
cases what he considered diseased conditions of 
the reproductive organs, and this led him to fix upon 
the reproductive organs as the seat, or at least the 
starting-point, of the disease. Cullen drew especial 
attention to the relationship existing between hys- 
teria and disorders of the gastro-intestinal tract. He 
regarded hysteria as an affection of the reproductive 
system, and makes the rather startling statement that 
the cause of the disease is " a mobility of the system, 
depending generally upon a plethoric state." 

Lisfranc gives the following summary, which he has 
modified from Brachet : " Many of the earlier authors 
believed with Hippocrates in the aberrations of the 



THE NATURE, ETIOLOGY, AND PATHOLOGY. 45 

uterus. A large number supposed the proximate 
cause of the disease to be the retention or putrefaction 
of the semen or menstrual blood and the distribution 
of malignant vapors over the body. More modern 
authors still, continued to regard the uterus as the 
seat of the disease, but supposed no other pathological 
alteration in its condition than some modification 
of its special nervous system, which reacted upon the 
general nervous system. Somewhat later it was be- 
lieved that hysteria was a general nervous affection 
with no more precise seat than the nerves. Hysteria 
has been located in the uterus (Hippocrates, Galen), 
the general nervous system (Pomme, Boerhaave, 
Sydenham), the brain (Willis, Georget), in the inferior 
portion of the spinal cord (Amard), in the stomach 
(Purcell, Vogel), in the lungs and heart (Highmore), 
in the vena porta (Stahl), and so on almost ad in- 
finitum!' 

As representing modern views on the nature of 
hysteria, the following quotation from Mills' admir- 
able article on hysteria, in Pepper's " System of Medi- 
cine," is given. This is a combination and modifica- 
tion of the most important theories held to-day re- 
garding the etiology of the affection. Mills says : 
" Comparing and analyzing the different views, it may 
be concluded, with reference to the pathology of hys- 
teria, as follows : (i) The anatomical changes in hys- 
teria are temporary.. (2) These changes may be at 
any level of the cerebrospinal axis, but are most com- 
monly and most extensively cerebral. (3) They are 
both dynamic and vascular ; the dynamic are of some 



46 HYSTERIA: ITS NATURE AND TREATMENT. 

undemonstrable molecular character ; the vascular 
are either spastic or paretic, most frequently the 
former. (4) The psychic element enters in that, 
either on the one hand, violent mental stimuli, which 
originate in the cerebral hemispheres, are transmitted 
to vasomotor conductors ; or, on the other hand, 
psychic passivity or torpor permits the undue activity 
of the lower nervous levels." 

The citations eiven above show how various have 
been the views held throughout the centuries regard- 
ing the nature of hysteria. Some of these theories 
are absurd, many fanciful, all without any underlying 
basis of fact. And yet they are not without their 
uses, for by picking out a bit here and a bit there 
that may appeal to our individual reason, we may be 
enabled to build up a theory that at least has the ad- 
vantage of affording a certain amount of personal 
satisfaction and explaining or harmonizing the phe- 
nomena of the singular condition which we call hys- 
teria. An unassorted mass of facts is a very difficult 
thing to handle practically, so that, in this case at 
least, an imperfect working theory is better than no 
theory at all. In our studies of the nervous system 
we are familiar with the division of the whole system 
into certain levels. One level stops at the cord in- 
cluding the peripheral system ; another reaches to the 
basal ganglia; a third includes the brain cortex. This 
mode of dividing the nervous system is, of course, 
arbitrary and does not follow developmental lines. 
A given sensorimotor reflex may stop at the cord, 
may extend to the basal ganglia, or may pass to the 



THE NATURE, ETIOLOGY, AND PATHOLOGY. 47 

cortex. Now, it is highly probable that this highest 
level, the cortex of the brain, is itself divisible. There 
exists a center which presides over the more mechan- 
ical working of the part which it represents, and we 
are coming to believe that all parts of the body are 
thus represented in the cortex. This might be 
denominated the subconscious cortical center. Upon 
its integrity depends the proper performance of 
the function of the part over which it presides. 
The spinal cord in all the higher animals acts as the 
aeent for the transmission and conversion of the im- 
pulses to and from this center. Beyond this sub- 
conscious center must be a conscious, volitional cen- 
ter, perhaps comprising one great center of volition, 
perhaps subdivided, each subdivision presiding over 
its own peculiar subconscious center. A movement 
of the limbs may be the result of a simple sensori- 
motor reflex reaching only the subconscious center, 
or it may be the result of a descending stimulus 
which starts directly from the center of volition. If 
the lower center be destroyed the mechanism is 
broken, and consequently the higher center is power- 
less to accomplish its purpose, though there may be 
present a consciousness of a violent effort to accom- 
plish this purpose. This is well illustrated in the 
attempts made to move a paralyzed limb, or, a more 
common example, the efforts to overcome the effects 
of a momentary pressure paralysis, as the sleep paral- 
ysis. In this latter case, to take a concrete example, 
we awaken at night after having lain upon the arm 
and attempt to move it. We are thoroughly con- 



48 HYSTERIA: ITS NATURE AND TREATMENT. 

scious of using some powerful effort to move the arm, 
but are utterly unable to do so until the compressed 
nerve resumes its function. In the same manner an 
individual with the arm center destroyed can go 
through a mental process of voluntary movement of 
the paralyzed part, which is certainly not a mere 
muscle memory. 

It is the function of these higher centers not only 
to stimulate and set in action the lower or subcon- 
scious centers, but also to inhibit, to diminish, or 
even entirely suspend their action. 

While this mechanism is more easily understood 
in regard to motion, it is probably no less true, 
though somewhat less comprehensible, in the do- 
main of sensation. We can, under the vigorous 
command of the higher centers, touch a heated sub- 
stance without great discomfort, which, if accident- 
ally brought in contact with the skin, would occasion 
sharp pain and elicit a very vigorous reflex. Or we 
can insert a pin into some not very sensitive part 
without any great pain, while an unexpected prick 
in the same region would be severely felt. On the 
other hand, the higher centers acting upon the 
lower may so greatly intensify sensation that a slight 
touch will often excite all the semblance of pain. In 
the same manner the centers presiding over the 
vasomotor and visceral systems are acted upon by 
the higher centers, which, ordinarily, do not inter- 
fere with what might be called the routine work. 
The sexual organs may be stimulated by central in- 



THE NATURE, ETIOLOGY, AND PATHOLOGY. 49 

fluence, for example, or vomiting may result from the 
idea that the food taken was poisonous or disgusting. 

It remains now to apply the above physiological 
reasoning, which, in part at least, is generally ac- 
cepted, to the phenomena of hysteria. 

Taking as examples the two most characteristic 
and frequent symptoms of hysteria, disturbances of 
motion, including spasmodic conditions, contract- 
ures, and paralyses, and disturbances of sensation, 
including hyperesthesia, paresthesia, and anesthesia, 
we are enabled to decide without difficulty what 
portion of the nervous system is responsible for 
their occurrence. If we test a case of hysterical paral- 
ysis by all the means known to us, we cannot evoke 
any symptoms suggestive of organic lesion. The 
reflexes are not altered to any extent, or at least 
not constantly so, the electric reaction is normal, nu- 
trition unimpaired. There exists only the impossi- 
bility of performing voluntary movements. The 
lower centers show no sign of disease, and we turn 
to the higher. As we know, the striking character- 
istic of these cases is that recovery, when it takes 
place, is often instantaneous ; the house takes 
fire, the physician or attendant speaks in a harsh 
manner, a pretended operation under an anesthetic 
is gone through with, in short, some strong mental 
shock or suggestion will, in an instant, dissipate all 
the paralytic symptoms. If the lower levels were 
affected, if the cord or peripheral nerves were in- 
volved, this result could not, of course, take place. 
We are forced, then, to the conclusion that the 

5 



1 



50 HYSTERIA: ITS NATURE AND TREATMENT. 

higher centers are at fault. For some reason, not 
as yet plain to us, the higher centers are unable to 
act upon the lower, under ordinary stimuli. When, 
however, the stimulus to the higher centers is very 
strong, as the instances above show, these centers 
are aroused to a degree of activity which allows 
them to emit a stimulus of sufficient force to excite 
the lower centers to action. 

In attempting to explain this clinical fact, we are 
hampered by our want of knowledge of the connec- 
tion which exists between the higher and lower 
centers, and also by the as yet imperfect ideas con- 
cerning the intimate structure of the nerve cell. 
The higher centers could be prevented from acting 
upon the lower either by a break in the connection 
supposed to exist between the two, or by a condition 
of the cells composing the higher centers. As to 
the first point, we know too little of the manner in 
which the different groups of nerve cells in the 
brain are connected to reason upon the nature of 
such connection. It may be that there is a distinct 
set of fibers which subserve this function, or that 
certain wave currents, transmitted independently of 
distinct fibers, bring the different centers into com- 
munication. As the question now stands, the most 
probable interpretation of the clinical facts of hys- 
teria is that the nerve cells are themselves affected, 
and are not able to send to the lower centers a 
stimulus of sufficient strength to excite these centers 
to action. It is, of course, much more rational to 
suppose that there exists in hysteria a functional 



THE NATURE, ETIOLOGY, AND PATHOLOGY. 51 

derangement, a temporary suspension of function 
in the active cell rather than in the almost passive 
fiber. The elaborate and valuable experiments of 
C. H. Hodo-e* on the working nerve cell are most 
suggestive in this connection. This observer has 
shown that if the posterior nerve root be stimulated, 
or if an animal be kept working in a treadmill, the 
ganglion cells become vacuolated, use up their proto- 
plasm, and that this protoplasm is renewed if the 
cells be allowed time for recuperation. Extending 
this reasoning, then, to the higher centers, we can 
conceive the cells in this region gradually becom- 
ing exhausted by a long-continued expenditure of 
energy. The rest is never quite long enough to 
repair the ravages of the work. According to our 
theory, it is the higher centers that are involved in 
hysteria, the centers that preside over volition and 
the intellectual processes. The lower centers are 
all in good order and fit for work, but the necessary 
voluntary impulse is wanting. 

Now the causes that are the most potent factors 
in the production of hysteria — such causes as bad 
environment, faulty training, in which the emotions 
are too largely drawn upon, excitement, grief, worry, 
emotional shock, and the like — furnish exactly the 
conditions that a priori we w T ould expect to be re- 
sponsible in' exhausting the nervous energy, using up 
the protoplasm of the cells composing the higher 
centers. These cells at length become exhausted to 

* Journal of MoJ-phology, 1 892. 



52 HYSTERIA: ITS NATURE AND TREATMENT. 

such a degree that an ordinary stimulus cannot 
arouse their activity, and they in turn cannot excite 
the lower centers. When, however, the stimulus to 
the higher centers is very intense or sudden, the 
cells of these centers use up some of what might be 
called their reserve or residual protoplasm, and a 
stimulus of sufficient force to arouse the lower cen- 
ters is liberated. 

This same line of reasoning will, with almost equal 
force, apply to the various symptoms of hysteria, 
either somatic or mental. It is necessary to bear in 
mind that in addition to the voluntary stimulus of 
which we have been speaking, the higher centers also 
exert a very important inhibitory influence, and that 
when either of these impulses are for a long time ab- 
sent, the lower centers, lacking this normal and neces- 
sary stimulus, are apt to undergo certain changes of a 
more or less temporary character ; in fact, Charcot 
has supposed that distinct organic changes may re- 
sult from lona-continued functional derangement. 
Regarding the higher centers in their recipient 
capacity, our theory would still seem to hold good. 
In hysterical anesthesia, or other disturbances of sen- 
sibility, the conducting paths are almost certainly 
normal, the fault being in the percipient centers. 
The distribution of the sensory disturbance, not con- 
forming to the nerve supply, its sudden onset and as 
sudden disappearance, together with entire absence 
of symptoms pointing to any actual lesion in nerve 
or cord, confirms this view. We are thus led to 
conclude that hysteria is an affection of the higher 



THE NATURE, ETIOLOGY, AND PATHOLOGY. 53 

brain centers, perhaps an actual though temporary 
loss of protoplasm. As a consequence of the in- 
volvement of these higher centers, voluntary move- 
ments are interfered with, sometimes evidenced by 
irregular or convulsive movements ; at other times, 
or perhaps at the same time, the percipient or recip- 
ient function of these same centers is involved, and 
the result is disturbance of sensation, either an exces- 
sive sensibility or anesthesia. Studying the mental 
phenomena of hysteria in the light of this theory, 
we see that the irregular mental action, the instability, 
emotional disturbance, the entire want of self-con- 
trol, the profound changes that are so apparent in 
the character of the individual, all point to a more 
or less serious involvement of the higher brain 
centers. 

It is, then, to these higher centers that we must 
look for the pathological changes in hysteria, and it 
is not going too far to predict that when our technic 
becomes more perfect than it is now, we shall be able 
to detect changes in the protoplasm of the brain 
cells which will clear up much of the mystery that 
attaches to mental disturbance, whether of a tempo- 
rary or permanent nature. The modern conception 
of the neuron has suggested an explanation of the 
phenomena observed in certain mental states, par- 
ticularly hysteria. It had been suggested from time 
to time that the neuron possessed a certain power 
of movement. This was later demonstrated by 
Wiedersheim * in the case of certain of the lower 

* Anatomischer Anzeiger, 1 890. 



54 HYSTERIA : ITS NATURE AND TREATMENT. 

orders, and the theory has thus received a partial 
confirmation. Of course, in the neurons of the 
brain cortex the only movement supposable is a 
contraction of the cell processes. This would, of 
course, cause a break in the path of conduction. 
Ramon y' Cahal * supposes the neuroglia cells to 
be endowed with contractility, or at least to possess 
the power of contracting their processes, and this he 
thinks acts as a sort of insulator between the nerve 
cells. Which ever of these hypotheses be correct, 
or, more properly, if either one of them prove by 
later experimentation to be tenable, a very plausible 
theory is afforded upon which to explain many of 
the phenomena seen in hysteria. Dercum, j* in a 
careful review of this subject, says : " Let us take the 
simple example of an hysterical paralysis, and see 
how easily it is explained. The neurons of a certain 
area of the cortex, for instance, retract the terminal 
branches of the neuraxons to such an extent that the 
latter are no longer in contact, or sufficiently near 
to the neurons in the spinal cord which supply the 
muscles of the paralyzed part. It explains also the 
marvelous fact that an hysterical paralysis may at one 
time be so real, so genuine, as to be indistinguishable 
from a grossly organic paralysis, and yet the next 
moment, upon a suggestion, may absolutely disap- 
pear. This shifting of symptoms in hysteria, this 
sudden disappearance of paralysis or anesthesia, can 

* " Les Nouvelles Idees sur la Structure du Systeme Nerveux." 
^Jour. of New. and Ment. Dis., August, 1896. 



THE NATURE, ETIOLOGY, AND PATHOLOGY. 55 

be explained by the view here advanced as it can by 
no other. When the power is suddenly re-estab- 
lished in a hysterically palsied limb, it simply means 
that the terminal branches of the cortical neuraxon, 
previously retracted, are again extended so as to 
re-establish the proper relations with the spinal 
neurons." 

Of course, in a disease like hysteria opportunity 
is rarely ever afforded for the study of the parts 
supposed to be involved, and hence our deductions 
must of necessity contain more of metaphysical 
reasoning and more of pure theory than befits an 
exact science. In the very name "hysteria" we are 
obliged to make a concession, for whatever we may 
or may not know about hysteria, this much is certain 
— that it has no causative dependence upon the 
uterus. The name, however, has become so fixed 
by immemorial usage that we can hardly hope ever 
to supplant it by some more fitting appellation. 



CHAPTER III. 

SYMPTOMATOLOGY. 

In considering the symptomatology of hysteria 
there necessarily arises an embarrassment, due to 
the comprehensiveness of the subject. The bound- 
ary lines marking the limits of what is loosely termed 
hysteria never have been, and from the nature of the 
subject never can be, very sharply drawn. Accord- 
ing to the ideas advanced in the last chapter, the 
pathology of hysteria consists in some alteration in 
the cells composing the higher centers, and our 
knowledge of the domain and limits of these centers 
is as yet undefined and hazy. We cannot clearly 
define what we mean by volition, since it is com- 
posed of many elements. We know, however, that 
in hysteria the fault lies in the center or centers 
which weigh and decide upon the considerations 
determining choice. In hysteria, the scale of the 
balance has been destroyed, and the relative value 
of impulses cannot be ascertained. So far as is 
known the impulses travel into the centers with 
their accustomed speed and ease, but the centers 
are incapable of putting the proper valuation upon 
them. The terminal apparatus of the sensory 
nerves, and the nerve fibers themselves, are in nor- 
mal condition, but the information they convey to 
the higher centers is either not interpreted at all or 

56 



SYMPTOMATOLOGY. 57 

misinterpreted. It is necessary to bear in mind that 
this condition of loss of protoplasm, of lowered nu- 
trition, which has been supposed to lie at the root of 
the pathology of hysteria, involves the idea of irreg- 
ular and incoordinate action, as well as inhibition. 
Immediately preceding loss of action, or sometimes 
accompanying it, is a condition of irritative action ; 
consequently we would expect a priori to find irregu- 
lar and excessive action in hysterical conditions as 
well as loss of action ; the same causes that are 
operative in producing paralysis will, in advance, 
occasion convulsive movements or contractures. 
The involvement of the cells composing the higher 
centers, the using up of their protoplasm, in all 
probability takes place in the irregular manner so 
often seen in chronic diseases of the gray matter of 
the spinal cord. Applying this method of reasoning 
to the functions of the higher centers, it is seen at 
once that in hysteria there may be present all grades 
of under- or over-action. Certain emotions may be 
greatly intensified, while others may be inhibited ; the 
imagination, the feelings, the will, all the higher 
functions are involved, now in a condition of irrita- 
tion, acting too strongly, feverishly, irregularly, now 
inhibited, not acting up to the normal standard. In 
the same way the sensory impulses, the afferent 
impulses generally, do not evoke the proper reflexes, 
now eliciting a too strong response, now failing to 
elicit any. Similarly the sum of the sensuous im- 
pulses is not sufficiently powerful to excite the 
centers presiding over what we know collectively as 



58 HYSTERIA: ITS NATURE AND TREATMENT. 

volition, and the result is loss, more or less complete, 
of intentional movements. Again, from the idea of 
the pathology of hysteria advanced above, there 
may exist all degrees of involvement of the cells ; 
the protoplasm may be slightly affected, greatly ex- 
hausted, entirely used up. Consequently there may 
exist all grades of symptoms belonging to the same 
class, the class itself being determined by the par- 
ticular group of cells invaded. 

It is necessary to speak with great reserve about 
the lighter phases of hysteria, since in functional 
diseases generally a very ill-defined and shifting 
line divides the normal from the abnormal. Having- 
only a theoretical pathology to guide us, we cannot 
lay down any hard and fast rule and say, "here the 
physiological stops and the pathological begins." 
Even if hysteria be conceived to be dependent upon 
an actual loss of the protoplasm of the cells compos- 
ing the higher centers, too little is known as yet about 
the nature of this protoplasm to make its increase 
or decrease a basis of classification. As a matter 
of convenience, the term "hysteria," or " hysterical 
temperament," has been applied to a class of cases 
the only symptom of which is a general instability 
or want of co-ordination of the nervous system. A 
given stimulus cannot be counted upon to provoke 
what might be called the normal or mean reflex. At 
one time the reflex called forth is out of all propor- 
tion greater than the stimulus would warrant ; again, 
it falls far below what would be expected. Particu- 
larly is this true of the mental states ; the emotions 



SYMPTOMATOLOGY. 59 

are unusually vivid and easily provoked, fits of uncon- 
trollable laughter succeed or are followed by equally 
uncontrollable outbursts of grief. The affections 
are often perverted ; likes and dislikes are very vio- 
lent and irrational. The whole being seems too 
delicately poised, or rather inaccurately poised, a 
hair now turning the scale violently, and now a 
weighty matter leaving it undisturbed. The proper 
relation between cause and effect is not perceived. 
Purely somatic symptoms are few ; an irregular 
vasomotor control, now overstimulation of the 
center, now inhibition ; sensations of heat and cold, 
flush and pallor rapidly succeeding each other. 
The appetite is irregular, at one time ravenous, again 
entirely wanting, always capricious. Sexual disturb- 
ances may be present, and probably are present 
more often and to a higher degree than is admitted. 
The sexual instinct may be excessive, deficient, or 
perverted, the latter being especially common. Sleep 
is irregular, restless, and broken by horrible dreams' 
Such, in brief, are some of the symptoms of the 
lighter forms of hysteria, or, more properly, of the 
hysterical temperament. These symptoms appear 
at, and are seen almost exclusively at or just prior to, 
puberty, and doubtless are very closely connected 
with the development of the sexual functions. This 
lighter form of hysteria is the form that is recog- 
nized popularly, and it is perhaps unfortunate that 
this is so, since it is often hard to convince the laity 
of the hysterical nature of certain graver symptoms 



6o HYSTERIA: ITS NATURE AND TREATMENT. 

when these lighter symptoms, which have for so 
long been regarded as cardinal, are absent. 

That this variety of hysteria is very common goes 
without saying, the point to be decided being to 
what extent it is to be regarded as a developmental 
phenomenon. The same set of symptoms, though 
far less pronounced, may be observed in old age, 
and it is extremely probable that both conditions 
owe their existence to a certain malnutrition of the 
cells composing the higher centers. In the vast 
majority of cases this light variety of hysteria never 
progresses beyond the lines here laid down, and the 
symptoms, while presenting more or less variation, 
in the main correspond to those described above. 
Undoubtedly these lighter forms of hysteria, or if it 
seems preferable to designate the condition merely 
as the hysterical temperament, prepare the ground 
for the more serious phases of the malady. Bad 
environment, faulty modes of life, injudicious educa- 
tion, and the like, will, of course, exert far more 
influence, in a direction favoring the development of 
grave hysteria, upon those cases in which the hys- 
terical temperament already exists than where this 
temperament is not pronounced. Hence it is at once 
apparent that these lighter forms of hysteria should 
be carefully studied in order to avert the threatened 
danger. 

Instead of following the French school, and divid- 
ing our subject into normal or interparoxysmal hys- 
teria and grand hystena, it is considered in its 



SYMPTOMATOLOGY. 61 

entirety. Conceiving the disease to be etiologically 
dependent upon some involvement of the cells com- 
posing the higher brain centers, it follows that the 
symptoms would present wide variations both as to 
kind and degree. Added to this it is quite probable 
that environment, education, suggestion, or racial 
influences induce important modifications. 

It is clearly impossible, then, to describe a typical 
case of hysteria as we would describe a typical case 
of typhoid fever. The most striking characteristic of 
the affection which we are discussing is its infinite 
variety. The symptomatology of hysteria includes 
the functions of the whole body. Again, we never 
know what symptoms to expect from an hysterical 
subject. It may be that an individual case continues 
for a very long time to exhibit only one or two of 
the characteristic phenomena of the disease, anes- 
thesia or paralysis ; or the whole train of symptoms, 
somatic and mental, may be present. Hence it fol- 
lows that the study of the symptomatology of hys- 
teria must be a study of individual symptoms, con- 
stantly bearing in mind the fact that in any given 
case any or all symptoms may present themselves. 

The headings under which this part of our sub- 
ject will be considered are as follows : 

i. Disturbances of sensation — anesthesia, pares- 
thesia, hyperesthesia, affecting both general sensi- 
bility and also the special senses. 

2. Disturbances of motion — paralysis, contracture, 
tremor, convulsive seizures. 

3. Vasomotor, visceral, and nutritive disturbances. 



62 HYSTERIA : ITS NATURE AND TREATMENT. 

4. Mental symptoms. 

5. Miscellaneous symptoms that do not belong 
to any of the foregoing classes. 

Anesthesia. — Of the multiform symptoms of hys- 
teria, the most characteristic and most constant is 
anesthesia. As has been noted in an earlier chap- 
ter, this symptom stands forth prominently in the 
epidemics of the middle ages. We read of the 
kicks and blows inflicted upon the apparently in- 
sensitive bodies of those affected with the dancing 
plague, and in all probability anesthesia played a 
part in the phenomenon of flagellation. Anesthesia 
was recognized as an incontestable sign of demoniac 
possession, and was resorted to as a test in the 
detection of persons supposed to be possessed by 
evil spirits. There were persons whose profession 
it was to detect those in league with the devil. 
When some unfortunate was accused of being pos- 
sessed, the magistrate would order an examination, 
which consisted in blindfolding the suspected per- 
son, stripping off the clothes, and pricking the skin 
with a needle to see if any spots of anesthesia could 
be found. This examination was intrusted to the 
" witch finder," or to a surgeon, and when spots of 
anesthesia were detected they were regarded as 
marks of the Evil One, and no other proof was 
needed for conviction. The unfortunate Urbain 
Grandier, whose sad case has already been referred 
to, was subjected to this test, and was declared to 
have " marks " or anesthetic spots on his body, a 
declaration that was probably false, since it was 



SYMPTOMATOLOGY. 63 

averred by many that they heard his exclamations 
of pain when the surgeon who made the examina- 
tion pierced his skin with the lancet. 

The acceptance of this test as a proof of demoniac 
possession caused such a large number of persons 
to be put to death that, in 1603, it was forbidden by 
the Parliament of Paris. 

In spite of the frequency and the striking nature 
of this symptom, anesthesia, it was not until near 
the middle of the present century that it was clearly 
recognized and studied as one of the most charac- 
teristic phenomena of hysteria. The credit of this 
recognition belongs, according to Briquet,* to Piorry, 
who pointed it out in 1843 \ somewhat later a care- 
ful study of hysterical anesthesia was made by Gen- 
drin in France f and SzokalskyJ in Germany. 

In speaking of sensation generally, it is important 
to bear in mind that it is made up of several com- 
ponent parts. Thus, we have tactile sense, pain 
sense, temperature sense, muscular sense, with, per- 
haps, some others less distinctly marked off. 

Hysterical anesthesia may involve all these vari- 
eties of sensation or only certain of them ; thus, a pa- 
tient may be absolutely insensible to any kind of 
stimulus, or may perceive tactile, without perceiving 
painful, sensations ; again, these last two may be 
normal, and temperature or muscular sense inter- 
fered with. Sensation is involved, in hysteria, in 



* Op. cit. | Bull, de VAcad. de Med., 1845. 

% " Von der Anesthesie," etc., Vierteljahr. f. die prak. Heilkn. 



64 HYSTERIA : ITS NATURE AND TREATMENT. 

widely different degrees ; there may be absolute 
loss, great impairment, or only slight blunting of the 
acuity of perception. It is important to bear this in 
mind,, since it is highly probable that many cases of 
slight involvement of sensation pass unrecognized. 
The methods of testing sensation require no spe- 
cial description ; the finger is the best instrument for 
testing tactile sensibility, since the amount of press- 
ure used can best be regulated in this manner. It 
is often necessary to use some form of esthesiom- 
eter in testing tactile perceptions, the principle de- 
pending upon the fact that the legs of the instru- 
ment must be separated a certain distance in order 
that the two points shall be perceived as two and 
not as one. A fairly accurate table of measure- 
ments has been worked out ; thus, the two points 
can be distinguished by the tip of the tongue when 
the distance between them is 1.5 mm. (^ of an inch) ; 
finger tips, 2 to 3 mm. ; tip of nose, 6 mm.; forehead, 
22 mm.; forearm, lower leg, and back of foot, 40 
mm.; back, 60 mm.; upper arm and thigh, 75 mm. 
It is necessary, of course, that the points of the in- 
strument be blunt. For testing pain sense a needle 
is used, and for temperature sense two test-tubes, 
one filled with hot, the other with cold, water. Mus- 
cular sense is tested by requiring the person exam- 
ined to touch different parts of the body, and by 
placing one limb in a certain position and having 
the subject describe the position and imitate it with 
the corresponding limb. Pressure sense is tested 
by different weights, all having the same bulk, as 



SYMPTOMATOLOGY. 65 

cartridges filled with shot, or balls with graduated 
weights in them. It is of interest, also, to examine 
the sensibility to the galvanic and faradic currents, 
since it often happens that tactile and pain sense 
may be entirely lost, while electric sensibility is more 
acute than normal. Of course in all these experi- 
ments the subject tested must be blindfolded. 

The frequency with which anesthesia in some form 
occurs in hysterical subjects is assuredly very great, 
thouo-h American and English observers would 
hardly indorse the statement made by Gendrin,* who 
says : " In every case of hysteria, without exception, 
from the beginning to the termination of the malady, 
there exists a condition of anesthesia, general or 
partial." Briquet states that in 240 cases there was 
not one in whom there was not some decree of 
anesthesia. 

According to most observers, the left side is in- 
volved twice as often as the right. Of the various 
forms of anesthesia, the most frequent is analgesia, 
or loss of pain sense. In these cases tactile sensi- 
bility remains perfect, and the patient feels the 
touch of the needle but experiences no pain. Next 
in order of frequency is loss of common tactile 
sensibility ; temperature sense is not infrequently 
disturbed or lost. Loss of muscular and articular 
sense has frequently been noted (Charcot,-}" Pitres,J 
Lasegue§), but occurs more rarely than disturb- 

* Loc. cit. -j- "Ouvres Completes." 

\ " Des Anesthesies Hysteriques," 1887. 

\ "Anesthesie et Ataxie Hysterique." Arch. Gs)i. de Med., 1864. 



66 HYSTERIA: ITS NATURE AND TREATMENT. 

ances of the other varieties of sensation. Dana * 
says, in regard to the disorders of cutaneous sensi- 
bility, that pain sense is oftenest affected, then tem- 
perature sense, then tactile sensibility, and that 
muscular sense and articular sensibility are rarely 
involved. 

The distribution of cutaneous anesthesia in hys- 
teria is very variable, complete or total anesthesia 
being quite rare. Briquet f has recorded but four 
cases out of 240. Gilles de la Tourette J has re- 
ported several cases in which the anesthesia in- 
volved the whole body, and other observers have 
recorded a few instances of this wide-spread disturb- 
ance of sensation. I have reported elsewhere a 
case of total hysterical anesthesia in a male subject. § 
Most frequently hysterical anesthesia appears in 
patches — disseminated anesthesia. Sometimes these 
areas are symmetrically disposed, but more fre- 
quently they are scattered irregularly over the body, 
having no definite shape and varying greatly in 
size. Occasionally one finds a single spot of anes- 
thesia of small size, and it is to be noted that this 
variety of anesthesia is usually very intractable. In 
a case under treatment at present there is an 
anesthetic patch, not as large as the palm of the hand, 
on the outer aspect of the left thigh, which has 
persisted for more than a year. Not infrequently 
part of one or more limbs may be involved, the 

* Am. Jour. Med. Set., 1 890. f Loc.cit. 

\ " Traite Clinique et Therapeutique de L' Hysteric" 
I " Trans. Amer. Neurolog. Assoc.," 1895. 



SYMPTOMATOLOGY. 



07 



anesthesia taking the shape of a stocking or long 
glove. An arm and leg on the same side may be 
affected, or an arm on one side and the leg of the 
opposite side. 




Fig. 



-Disseminated Anesthesia. 



The most characteristic variety of hysterical anes- 
thesia is hemianesthesia, and this form is seen nearly 
as often as all the other varieties taken together. 
Hysterical hemianesthesia divides the body into two 



68 



HYSTERIA: ITS NATURE AND TREATMENT. 



equal parts by a vertical plane passing through the 
middle line, one-half being normal, the other anes- 
thetic. 

The dividing line is drawn with the utmost accur- 




Fig. 2. — Glove and Stocking Form of Anesthesia. 



acy ; the body is exactly bisected vertically, and the 
anesthetic and normal parts are sharply separated, 
with no tendency to shade into one another. It will 



SYMPTOMATOLOGY. 



69 



be noted that the classification here employed differs 
somewhat from that generally used, in that only two 
varieties of anesthesia are recognized — the dissemi- 
nated, including that variety of anesthesia which 




Fig. 



-Hemianesthesia. 



occurs in irregular patches, as well as the glove and 
stocking type, and hemianesthesia. If the former 
of these varieties be subdivided into several groups, 
then the hemianesthetic form is much the more 



70 HYSTERIA: ITS NATURE AND TREATMENT. 

common, but if only two varieties are recognized then 
the irregular form is oftener seen than distinct hemi- 
anesthesia. 

Total anesthesia is, as has been said, a compara- 
tively rare form, and no separate class need be 
made for it. Not infrequently cases are met with 
in which there is a distinct obtunding of sensation 
over the whole body. This diminution of sensation 
is not sufficiently marked to speak of it as anes- 
thesia, and it is the appreciation of painful impres- 
sions that is blunted rather than any disturbance of 
tactile sense. 

It rarely, if ever, happens that hysterical anesthesia 
is sharply limited to the upper or lower half of the 
body. Occasionally in hysterical paraplegia, as Char- 
cot has pointed out, the lower limbs are anesthetic, 
but even this is rare. 

A study of the various forms of hysterical anesthe- 
sia shows at a glance that there is no tendency for the 
affection to follow the course of the peripheral nerves. 
In seeking for analogies between hysterical and or- 
ganic anesthesia it will be seen that irregular or dis- 
seminated anesthesia of hysterical origin corresponds 
to anesthesia due to cortical disease, while the second 
variety, in which one-half of the body is involved, re- 
sembles very closely organic hemianesthesia due to 
a lesion of the capsule. In fact, it is sometimes diffi- 
cult to determine, without invoking the aid of other 
symptoms, whether hemianesthesia is organic or func- 
tional. The skin over the anesthetic area presents 
no peculiarities to the eye, except certain rather rare 



SYMPTOMATOLOGY. 71 

vasomotor changes that will be noticed in another 
chapter. The surface temperature is frequently a 
little lower than that of the corresponding normal 
part, and it is true, as was claimed in the epidemics 
of St. Medard, that blood is not as easily drawn from 
the affected as from the normal surface. Charcot 
and Grisolle have both noted the difficulty experi- 
enced in drawing blood by means of leeches from 
anesthetic areas. The reflexes on the anesthetic 
side are somewhat altered, the skin reflexes being 
in great part abolished and the deep reflexes some- 
times diminished, sometimes rather more active than 
normal. The observation of Rosenbach, that the 
abdominal reflex is lost in certain cases of intracranial 
lesion and always preserved in hysterical conditions, 
has not been confirmed. 

The anesthesia of hysteria is by no means confined 
to the skin ; in marked cases the deeper structures, 
muscle and bone, are also involved. Very often the 
abdominal viscera show marked analgesia, and can 
be compressed and manipulated in a manner not pos- 
sible under ordinary circumstances. Anesthesia of 
the mucous membranes is very common. The conclu- 
sions of Lichtwitz,* who has made a careful study of 
this part of the subject, are as follows : (i) Anesthesia 
of the mucous membranes usually follows the nature 
and degree of the cutaneous anesthesia. (2) Total 
hemianesthesia of the mucous membranes is exceed- 
ingly rare. (3) The buccal mucous membrane gener- 

* " Les Aneesthesies Hysteriques des Muqueuses," 1887. 



72 HYSTERIA: ITS NATURE AND TREATMENT. 

ally shows incomplete anesthesia. (4) The mucous 
membrane of the nose is never totally hemianesthetic. 
(5) Anesthesia of the epiglottis is not a constant nor 
pathognomonic symptom of hysteria. In regard to 
hysterical anesthesia of the larnyx, Thaon * says : 
"Anesthesia (hysterical) may occupy the entire larynx 
and be absolute ; usually it is bilateral and not con- 
fined to the distribution of any special nerve." 
Often this condition is associated with paralysis of 
the vocal cords. Anesthesia of the mucous mem- 
brane about the anus is very rarely met with ; some- 
what more common is anesthesia, or at least anal- 
gesia, of the mucous membrane lining the urethra and 
vagina. It is very common to find sensory disturb- 
ances associated with some of the motor symptoms 
of hysteria, such as paralysis, contracture, or convul- 
sive movements. 

The onset of hysterical anesthesia, like most of the 
other symptoms of the disease, is apt to be sudden, 
and is noted especially after paroxysmal seizures, 
convulsions, paralysis, contractures, and the like. 
Anesthesia, however, is mostdistinctly an interparox- 
ysmal symptom, and is certainly the most constant and 
pathognomonic of the so-called stigmata. It is inter- 
esting to note that a wide-spread anesthesia may exist 
for a long time without the subject being aware of 
it. In a case seen a few years ago a complete hemi- 
anesthesia had existed, probably, for several years, 
entirely unrecognized by the patient. 

* " L' Hysteric et le Larynx," 1881. 



SYMPTOMATOLOGY. 73 

The danger of confounding cutaneous anesthesia 
of hysterical nature with anesthesia due to some 
organic lesion is not great. 

It is true that hemianesthesia due to a lesion in the 
capsule may resemble almost exactly a similar condi- 
tion of hysterical nature, except that in the organic 
form there is usually seen a facial paralysis along 
with hemiplegia, and, perhaps, hemianopia ; cases 
have been reported, however, of hemianesthesia of 
capsular origin corresponding almost perfectly to 
hysterical hemianesthesia. Syringomyelia often pre- 
sents wide-spread and irregular areas of anesthesia, 
but the other symptoms of this affection, particularly 
the very marked trophic symptoms, are not likely to 
be confounded with functional anesthesia. In certain 
toxic anesthesias, due to alcohol, lead, arsenic, and a 
few other poisons, very marked anesthesia may exist, 
but in these conditions there exists a distinct neuritis 
which can be readily recognized. 

Special Senses. — The sense of touch has al- 
ready been considered when speaking of the vari- 
ous forms of anesthesia; of the remaining special 
senses there are two that we should expect to be in- 
volved along with anesthesia of the mucous mem- 
branes, namely, taste and smell. In accordance with 
the views expressed as to the central nature of 
hysteria, disturbances of the special senses occur 
without any involvement of the sense organs. In 
the case of taste and smell, however, the association 
between general and special sensation is very close. 
The sense of smell is a very feeble sense in the human 
7 



74 HYSTERIA: ITS NATURE AND TREATMENT. 

subject, and, as Foster* says, "the psychic devel- 
opment of simple olfactory sensations is extremely 
scanty." Moreover, as Lichtwitz has shown, the 
nasal mucous membrane is far less apt to be affected 
with tactile anesthesia than mucous surfaces else- 
where. The sense of smell in hysterical subjects has 
never been carefully examined. The author just 
quoted states that loss of smell generally coincides 
with the loss of tactile sense in the nasal mucous 
membrane. He noted both unilateral and bilat- 
eral loss of smell ; total, as well as loss of perception 
of certain odors only. Briquet states that loss of 
smell is generally unilateral, corresponding to the 
loss of general sensation. Dana -f has found smell 
lost only in cases of hemianesthesia. In one of my 
own cases, a case of total anesthesia in the male, 
there was entire loss of the sense of smell, which 
symptom persisted for several months. The forego- 
ing remarks apply in the main to the sense of taste. 
Loss of the sense of taste is probably always asso- 
ciated with more or less loss or impairment of smell, 
and with a corresponding loss of tactile sensibility 
over the tonoue and mucous membrane of the mouth. 
Lichtwitz has noted that it frequently happens that 
the sense of taste is lost over part of the tongue 
only, while the whole of the mucous membrane is 
anesthetic. No very well authenticated case of loss 
of taste without loss of general sensibility has been 
recorded. 

*" Text-book of Physiology." f Loc. at. 



SYMPTOMATOLOGY. 75 

Taste in hysterical subjects is often perverted, so 
that disagreeable, or even repugnant, substances are 
frequently eaten with apparent relish. In regard 
to the loss or impairment of these two senses in 
hysteria, it must not be forgotten that both these 
special senses are subject to great individual varia- 
tion. In the case of my own mentioned above 
there was absolute loss of taste. The patient was 
utterly unable to distinguish between the most 
diverse substances. As he began to improve he 
complained of his coffee being too sweet, and of his 
food being too highly seasoned. Gilles de la Tour- 
ette thinks that loss of both smell and taste are 
not uncommon. Hysterical deafness would seem to 
be more common than loss of smell or taste. In 
most if not all cases of hysterical deafness there is 
anesthesia of the meatus auditorius externus, and 
often of the outer surface of the tympanum, this 
anesthesia being a part of the general tactile dis- 
turbance. Testing such patients with the tuning- 
fork shows that the deafness is central ; aerial con- 
duction is much better than conduction through the 
bones of the head. They will hear the tuning-fork 
when it is placed on the forehead or upon the teeth 
only on the unaffected side, or, if both sides are in- 
volved, they will hear better if the tuning-fork be 
held close to the ear than if it be placed in contact with 
the teeth. Again, Dana* has made the interesting 
observation that deafness to low notes is rare, thus 

* Loc. cil. 



76 HYSTERIA : ITS NATURE AND TREATMENT. 

furnishing an analogue to the limitation of the visual 
field. Hysterical deafness may be either unilateral 
or bilateral, and, in degree, complete or partial. 
Walton,* from a study of cases at the Salpetriere, 
concludes that (i) " the sensibility of the deep parts of 
the ear, including the tympanum and middle ear, 
disappears in hysterical hemianesthesia with that of 
other parts of the body and in the same degree. 
(2) The degree of deafness corresponds with that 
of the general anesthesia, being complete when the 
latter is complete, and incomplete when the latter is 
incomplete." 

Vision. — One of the most constant symptoms 
of the interparoxysmal stage of hysteria is dis- 
turbance of vision. Dana says: "The most con- 
stant form of sensory anesthesia is limitation of 
the visual field." Visual disturbance in hysteria 
may take several forms. There may be total loss 
of sight — hysterical amaurosis. This is certainly 
a rare affection ; cases have been mentioned by 
Briquet,f Charcot,^ Harlan, § Gilles de la Tour- 
ette, I J Pitres,** Parinaud,-j-j- and others. See also an 
interesting paper on this subject by Booth. %\ The 
affection is more often unilateral, though there may 
be total blindness in both eyes. Quite frequently 
it comes on immediately after a convulsive attack. 
The duration is usually short, though in Harlan's 



* " Brain," vol. V, 1882. f Op. cit. % Op. cit. 

I Med. News, Phila., 1890. || Op. cit. ** Op. cit. 

ff Arch, de Neurol., Paris, 1889. \% " Trans. Amer. Neurolog. Assoc," 
1895. 



SYMPTOM ATOLOCxY. 77 

case it lasted for several years. It is often possible 
to demonstrate the central nature of hysterical amau- 
rosis in a very simple way, either by using different 
colored glasses, so chosen that the combination of 
colors made shows the perception of both colors, or 
by employing the stereopticon in the case of mon- 
ocular amaurosis. It is sometimes difficult to de- 
cide whether we have a case of hysteria or merely 
one of malingering to deal with. Of course the 
presence of other hysterical stigmata aids the diag- 
nosis, and while the eye defects will by no means 
always exactly correspond upon repeated examina- 
tions, still they are far more consistent than in the 
malingerer. As has been noted, the most char- 
acteristic form of visual defect in hysteria is limita- 
tion of the visual field. The normal field for white 
light is concentrically constricted until only central 
vision remains. Visual acuity, as a rule, remains 
good, though there may be varying degrees of 
amblyopia. No changes have been perceived by 
the use of the ophthalmoscope. As was noted 
above, there is usually present anesthesia of the 
cornea. The restriction of the visual field is bi- 
lateral, though the two eyes may be affected in dif- 
ferent degrees. This has given rise to the question 
as to whether we ever have what might be called 
hysterical hemianopia. The weight of evidence is 
clearly against the occurrence of this form of eye 
defect in hysteria. Briquet* and Galezowskif have 

* Loc. cit. f " Prog. Med.," 1878. 



78 HYSTERIA: ITS NATURE AND TREATMENT. 

reported cases of so-called hysterical hemianopia, 
though perhaps the most credible cases are one by 
Lloyd * and another by Mitchell and De Schweinitz.-j- 
If the condition does exist, it is certainly extremely 
rare. Knies and Leber J endeavor to explain these 
unilateral disturbances of vision in hysteria by com- 
pression of the optic nerve at the foramen, due to 
vascular dilatation. This would seem rather a fanci- 
ful explanation, and would put the eye disturbances 
outside the pale of pure hysterical phenomena, since 
practically all the other symptoms of hysteria can be 
satisfactorily explained on the theory of a central 
disturbance. 

As has been noted above, the visual field in hys- 
terical amblyopia is restricted, and this limitation is 
concentric and regular, thus differentiating it pretty 
clearly from organic limitation of the field. The 
field of vision on the side of the hemianesthesia is 
usually much more markedly restricted than on the 
other side, and, as Landesberg has shown, the re- 
striction varies with different attacks, although the 
violence of the attack seems to bear no definite 
relation to the extent of the visual disturbance. 
Fere, on the other hand, is inclined to believe that it 
is rather the inaccuracy of the perimetric examina- 
tions that causes the variations that are so frequently 
observed. As we have seen, the restriction of the 
visual fields varies from a scarcely appreciable limi- 

*" Text-book of Nervous Diseases," Dercum. 

f Jour, of A T erv. and Men t. Dis., 1 894. 

I " Handbuch der Augenheilkunde," Band V. 



SYMPTOMATOLOGY. 79 

tation up to complete amaurosis. The examination 
must be carefully made with a perimeter, and it is 
necessary to bear in mind that the eye becomes 
rapidly fatigued, especially in hysterical subjects, and 
consequently the results may be vitiated by too long 
sittings. Besides the limitation of the visual fields 

o 

to white light there exist at the same time decided 
disturbances of the color fields. There may be total 
loss of color perception, achromatopsia, or only dis- 
turbance of the relative position and extent of the dif- 
ferent color fields. The first of these conditions, acro- 
matopsia, is not common, at least in this country. 
When it exists all objects appear of a uniform gray 
or sepia color. The second variety of color disturb- 
ance is very frequently met with in hysteria. This 
consists of a perversion of the normal color fields, 
or of a reversal of the fields. In the normal eye the 
fields for colors are not co-extensive. Thus, the 
largest field is for white light; then come blue, red, 
and preen. The smallest field is that for violet. In 
hysteria these relations are altered. In some cases 
there is a simple restriction of the color fields, in 
their normal order, but nearly always there is a re- 
versal of the fields. Thus, the most frequent change 
is between the red and blue. Instead of blue oc- 
cupying the largest field, as it does normally, its 
place is taken by red. Parinaud, commenting upon 
the fact that in hysteria the largest color field is that 
for red, says that perhaps the well-known predilec- 
tion of hysterics for red may be thus explained. 
From a careful analysis of a large number of hys- 



8o 



HYSTERIA: ITS NATURE AND TREATMENT. 



terical visual defects, Mitchell and De Schweinitz* 
draw the following conclusions: (i) Achromatop- 
sia is not present in the American cases. (2) Re- 
versal in the normal sequence of the colors, so that 
red is the largest field, is usually present when there 
is anesthesia, but disturbance of color sense is not 



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Fig. 4. — Normal Visual Field. The unshaded portion of the diagram 

shows form field. Line blue field ; line + + + + red field ; line 

— I 1 V green field. 

necessarily associated with anesthesia. (3) The 
green field is, relatively at least, more and more 
often contracted than any other. (4) The violence 
of the hysterical manifestation bears no relation to 
the disturbance of the color sense. (5) The most 



'Jour, of Nervous and Mental Dis. , 1894. 



SYMPTOMATOLOGY. 



« 




82 HYSTERIA : ITS NATURE AND TREATMENT. 

frequent changes in the visual fields are : (a). Sim- 
ple contraction for color but not for form ; (b) con- 
traction of fields for both ; (c) partial or complete 
reversal of normal sequence in size of color fields, 
the red being most commonly the largest ; (d) loss 
of parts of the visual field, as in the form of a hemi- 
anopia, or greater contraction of the field on one side 
than on the other, the greater contraction usually 
being found on the same side with the anesthesia. 

A symptom that is sometimes observed in hysteria 
is polyopia. Generally, only two or three images of 
an object will be seen, but occasionally more. Ul- 
rich* mentions a case in which six images were per- 
ceived. When there are two images, the false one 
is outside ; when there are three, the two false 
images are on either side of the true. According 
to Pansier -j- the images are not always on the 
same level, and sometimes one seems nearer the 
eye than another. Concerning the nature of hyster- 
ical polyopia the same author concludes that, while 
muscular defects have an important bearing in the 
production of the visual disturbance, it must be ad- 
mitted that it is in part cerebral. There are some 
facts that cannot be explained by hysterical involve- 
ment of the eye muscles. 

It is always necessary to bear in mind the extreme 
susceptibility of hysterical subjects to suggestion. 
The commonly observed visual hallucinations are, in 



* Monatshl. f. Augenheilk., 1882. 

f " Les Manifestations Occulaires," Paris, 1892. 



SYMPTOMATOLOGY. 83 

all probability, due to suggestion, as are, perhaps, 
the conditions sometimes observed of megalopsia or 
micropsia. 

The various affections of the eye muscles seen in 
hysteria will be described in another place. 

Visual disturbances occurring in hysteria have 
long been recognized. Omitting vague references 
to hysterical blindness in the early medical writings, 
we find distinct reference to hysterical visual disturb- 
ances in the writings of Charles Lepois in 1618, 
and later by Pomme, Hocken, Szokalski, and others. 
The great value and significance of this symptom 
was not appreciated until the appearance of the 
papers of Charcot, Galezowski, Parinaud, and Fere. 
The subject has been very carefully studied in this 
country by Mitchell and De Schweinitz. 

Paresthesia and Hyperesthesia. — Not as con- 
stant or as characteristic as anesthesia, but still 
occurring commonly during the course of hysteria, 
are certain perverted or abnormally active manifes- 
tations of sensation. Just as we see the motor dis- 
turbances varying from convulsion to paralysis, so 
sensation may be greatly heightened, or entirely lost. 
Paresthesias of all kinds are met with in hysteria. 
Undoubtedly these may sometimes have the value 
of hallucinations or illusions, with an organic basis. 
Slight nutritive disturbances may alter the skin, and 
thus furnish a foundation for the sensory phenomena. 
Or there may be a slight neuritis present, such as is 
not infrequently seen affecting the hands or feet of 
elderly people. As a rule, however, the paresthe- 



84 HYSTERIA: ITS NATURE AND TREATMENT. 

sias of hysteria, like the other phenomena of the dis- 
ease, are of central origin and not dependent upon 
any structural alteration in the sense organ. Very 
often these perverted sensations take the form of 
flashes of heat or cold, either local or general. 
Again, and this is one of the most familiar of the 
hysterical paresthesias, there is present the sensation 
of insects crawling over the skin, or a feeling as of 
a snake or lizard under the skin. One of the most 
common forms of perverted sensation is that of 
numbness, and this is often accompanied by, or alter- 
nates with, sensations of pricking, tingling, burning, 
and the like. This sensation of numbness in hys- 
teria is purely subjective, and must not be con- 
founded with light grades of anesthesia. It is impos- 
sible to classify these perverted sensations, since the 
cause is central, and there is no limit to their extent 
except the imagination and vocabulary of the sub- 
ject. In my own experience the paresthesias of 
hysteria do not follow any fixed rule either as to 
location or extent. Sometimes the disturbance is 
confined more or less to one side, but usually the 
distribution is irregular. Negroes seem particularly 
prone to these disturbances of sensation. 

After studying hysterical anesthesia, and observ- 
ing how distinct, regular, and well marked are its 
areas of distribution, one is rather surprised to find 
that hyperesthesia and, as was just mentioned, par- 
esthesia by no means follow the same lines. Gen- 
eral hyperesthesia of the skin of the whole body is 
not common, at least in any marked degree. It is 



SYMPTOMATOLOGY. 85 

by no means unusual to hear hysterical patients 
complain of " tenderness " over the entire body, but 
distinct general hyperesthesia is comparatively rare. 
The same may be said of a one-sided hyperesthesia, 
corresponding to the commonly observed hemi- 
anesthesia. Such cases have been recorded by 
Briquet, Gilles de la Tourette, and others, but they 
certainly occur but rarely. Disseminated hyper- 
esthesia is the most common variety ; islets or 
patches, exquisitely sensitive, sometimes occupying 
a considerable area, oftener of small extent, are to 
be seen in a large number of hysterical subjects. 
These hyperesthetic patches may occur side by side 
with areas of anesthesia. One of the characteristic 
features of hysterical hyperesthesia is that while a 
light touch excites lively pain, firm, hard pressure is 
not painful. This, however, is not an invariable 
rule. It will be noticed that in this connection no 
distinction is drawn between hyperesthesia and 
hyperalgesia. This hyperesthesia is not confined 
to the skin, but is quite frequently observed in 
deeper structures. The mucous membranes, vagina, 
urinary passages, rectum, mouth, or throat, may 
be the seat of an exquisite hypersensibility. The 
vagina and urinary passages are most commonly 
affected in this way, giving rise to the well-known 
symptoms of vaginismus and painful micturition. 
Cases have been reported in which it became very 
difficult to take food in the ordinary way, owing to 
the extreme sensitiveness of the mucous membrane 
of the mouth, throat, or esophagus. Reference has 



86 HYSTERIA: ITS NATURE AND TREATMENT. 

already been made to the hypersensitiveness of the 
organs of special sense other than the skin, giving 
rise to curious disturbances in vision, hearing, smell, 
and taste. It is thus seen that only in a very gen- 
eral way does hysterical hyperesthesia correspond 
to the opposite condition — anesthesia. 

Belonging to the same general category of hyper- 
esthesias are the very common painful affections 
met with in hysteria. Hysterical pains may be 
superficial, corresponding roughly to the distribution 
of certain nerves, or they may be deep and ap- 
parently associated with, or at least referred to, the 
brain, spinal cord, articulations, or thoracic or ab- 
dominal viscera. To the first category belong the 
various forms of hysterical neuralgia. Of course, it 
is difficult to speak with any degree of certainty 
about hysterical neuralgia. Pain along the course 
of a nerve, or at its point of emergence from a canal, 
is still of too obscure a nature to admit of the dis- 
tinction being sharply drawn between what is and 
what is not hysterical. Headache, of various kinds, 
is quite common among hysterical subjects, and so 
far as we can judge is often a purely hysterical 
symptom. The most characteristic of these head 
pains, though among the rarest of them, is the clavus 
hystericus, so graphically described by Sydenham. 
The seat of this pain is usually the vertex, and it 
is generally limited to a very small area. The 
intensity of the suffering and the concentration to 
one spot, suggested to the older writers, often so 
happy in their similies, the idea of a nail being driven 



SYMPTOMATOLOGY. 87 

into the skull. The duration of clavus hystericus is 
variable, lasting from a few hours to several days. 
Hysterical head pains of this nature have given rise 
to the expression " pseudomeningitis," which will be 
considered further on. Trifacial neuralgia, pain in the 
temple or eyes, a sort of migraine, hysterical tooth- 
ache, — this latter having been described by Syden- 
ham, — are some of the more important varieties of 
face pains that are common in hysterical subjects. 
Pain is often felt in the throat, associated with the 
well-known globus hystericus, or with aphonia. The 
most common form of hysterical pain occurring in 
the trunk is intercostal neuralgia. This pain does not 
follow strictly the distribution of the intercostal nerves, 
but is very often complained of over the region of 
the heart, and is commonly associated with palpita- 
tion or a sensation of movement of the heart. Pain 
in the region of the heart will sometimes, in hysteri- 
cal subjects, more or less closely simulate angina 
pectoris. The suffering is intense, the pain radiates 
through the chest and down the arms and is attended 
with many of the mental symptoms of the organic 
disease. The condition of the heart, the age of the 
patient, the provoking causes, and the fact that the 
hysterical affection generally occurs with great fre- 
quency, indicate the correct diagnosis in most cases. 
Pain in the mammary gland — " hysterical breast " 
— has long been known, though its hysterical nature 
was not at first generally recognized. An excellent 
description of it is given by Brodie. The affection 
is nearly always unilateral, and the pain, which is 



88 HYSTERIA: ITS NATURE AND TREATMENT. 

intense, is situated in the mammary gland, but may 
radiate down the arm. There can be no doubt of 
the fact that now and then cases of undoubted 
hysterical nature are seen in which there is slight 
tumefaction and even redness of the skin. The 
mammary gland is one of the marked hysterogenic 
zones, and irritation of the skin, as by light rubbing 
or manipulating the gland, will often bring on con- 
vulsive paroxysms. 

Probably the frequent occurrence of cancer in this 
region has done much to determine, through sugges- 
tion, the seat of this hysterical manifestation. The 
recognition of the hysterical breast is important, 
since it has happened that amputation has been re- 
sorted to on the supposition that some grave organic 
disease existed. 

The fact that has been mentioned — namely, that 
distinct tumefaction has not infrequently been ob- 
served in cases the nature of which was perfectly 
clear — makes the differential diagnosis not always 
easy. As a rule, other marked hysterical symptoms 
exist : rubbing of the breast induces a paroxysm of 
a hysterical nature, and, finally, a cure can nearly 
always be brought about by a psychic form of treat- 
ment. 

Another very common seat of hysterical pain, 
either spontaneous or provoked by pressure, is the 
vertebral column. As a rule, the nape of the neck, 
the region so frequently complained of in neuras- 
thenia, is not involved, or at least is not so much in 
evidence as the rest of the vertebral region. The 



SYMPTOMATOLOGY. 89 

pain may exist as a more or less continuous dull 
aching, or may appear only when pressure is made 
over the spine. These cases may sometimes be 
mistaken for Pott's disease ; in fact, the French 
school recognizes a pseudo-Pott's disease. Brodie * 
long ago called attention to the resemblance between 
the early stages of spinal caries and its hysterical 
imitation. Careful examination, watchful and intel- 
ligent observation, and proper treatment will rarely 
fail to clear up the nature of the case. More com- 
mon than the foregoing symptom is what is called 
hysterical arthralgia. Brodie recognized the im- 
portance of this affection, or rather the close resem- 
blance which often exists between hysterical and 
structural joint disease, and has left a number of 
valuable observations on the subject. He says : 
" There is a class of cases of no infrequent occur- 
rence in which the patient suffers considerable dis- 
tress in consequence of pain referred to some of the 
larger articulations. The disease appears to depend 
on a morbid condition of the nerves, and may be 
regarded as a local hysterical affection. At first 
there is pain, referred to the hip or knee or some 
other joint, without any evident tumefaction ; the 
pain soon becomes very severe, and by degrees a 
puffy swelling takes place ; the swelling is diffuse 
and in most instances trifling. There is always 
exceeding tenderness, connected with which we may 
observe this remarkable circumstance : that gentle 

* " Diseases of the Joints." 



90 HYSTERIA: ITS NATURE AND TREATMENT. 

touching or pinching the integument, in such a way 
that the pressure cannot affect the deeper seated 
parts, will often be productive of much more pain than 
the handling of the limb in a more rude and careless 
manner." 

As a rule, only one joint is involved, and the joints 
most usually affected are the knee and hip. Char- 
cot states that of 70 cases of hysterical arthralgia 
the knee was the seat of the affection in 38 in- 
stances, the hip in 18, the wrist in 8, the shoulder 
in 4, and the ankle in 2. There is generally a 
zone of hyperesthesia about the affected joint. Of 
course, careful examination under an anesthetic 
will often, though by no means always, clear up the 
case. It is in this class of cases that traumatism 
plays such an important part, and a great proportion 
of such cases are attributed to accidents which are 
nearly always trivial. 

There is a variety of hysterical hyperesthesia, 
constant and characteristic, about which so much has 
been said and written that it may be called a classic 
symptom of hysteria — ovarian tenderness. It has 
long been recognized that tenderness over the belly 
was characteristic of hysteria. This symptom fig- 
ures largely in the accounts that have come down to 
us of the violent epidemics of hysteria of the middle 
ages. This tenderness was vaguely located in the 
lower part of the abdomen, and it was reserved for 
Charcot to show that the pain was deep-seated, and 
either in the ovary itself or its nerve-plexuses. This 
fact — the location of the pain in the ovary and not 



SYMPTOMATOLOGY. 91 

in the abdomen generally — has been amply con- 
firmed by years of observation since its first an 
nouncement. Many cases of displaced ovary in 
hysterical subjects have proved that the tenderness 
is in, and not around, the gland. Of course, this 
applies to normal, and not to diseased, ovaries — a 
fact that has not been fully appreciated, since many 
ovaries are annually removed because of the hys- 
terical pain located in them. Sometimes in males 
there are tender spots corresponding to the situa- 
tion of the ovaries in the female. In a case of hys- 
teria in a man, recently under my care, these tender 
zones were very well marked. In certain cases of 
hysteria in the male the testicles seem to be abnor- 
mally sensitive to pressure, and not infrequently 
the seat of pain or disagreeable sensations. The 
mammary glands often present painful areas, and 
there are two distinct painful spots, one just 
above, the other below, the gland. These circum- 
scribed areas of hyperesthesia are known as hys- 
terogenic zones. The most constant and charac- 
teristic are the ovarian, the mammary, the supra- 
and infra-mammary, and the spinal. Many other 
zones have been described — about the head, throat, 
scapulae, intercostal region, limbs, mucous mem- 
branes, etc. ; but the ones mentioned above are the 
most important. The significance of these hystero- 
genic zones, as first described by Charcot, is that 
light pressure or rubbing at these spots induces 
some hysterical paroxysm, sometimes slight, again 
severe, depending upon the nature of the special 



92 



HYSTERIA: ITS NATURE AND TREATMENT. 



case. After the induction of the hysterical par- 
oxysm, forcible and long-continued pressure will in 




Fig. 6. — Hysterogenic Zones [anterior). 



many cases cut short the paroxysm. It is interest- 
ing in this connection to recall the curious proced- 



SYMPTOMATOLOGY. 



93 



ures, mentioned in chapter i, which were prevalent 
in the epidemics of the middle ages : such as tying 




Fig. 7. — Hysterogenic Zones [posterior). 



a cord tightly around the waist and twisting a 
stick which was thrust into it until the paroxysm 



94 HYSTERIA: ITS NATURE AND TREATMENT. 

ceased ; and a similar treatment — that of striking or 
kicking the abdomen of a person seized with a fit. 

The following cases will illustrate the phenomena 
of hysterogenic zones : A negro girl was brought into 
the City Hospital with grand hysteria. She lay on 
the floor in the " crucifix attitude," perfectly still and 
rigid, until the ovarian or inframammary regions 
were pressed upon, when a convulsive seizure would 
come on. In this case deep pressure did not entirely 
succeed in breaking up the attack. Another girl in 
hysterical lethargy could only be awakened by deep 
pressure over the ovary. A young married woman 
was thrown into an attack of grand hysteria by rub- 
bing the spinal region, and the attack was cut short 
by continuous forcible pressure in the same region. 
In none of these cases had similar procedures ever 
been resorted to, so that there could have been no 
element of suggestion. Sometimes one of these 
zones, sometimes another, will be found most sensi- 
tive; and, on the other hand, patients profoundly 
hysterical may exhibit no hysterogenic areas. In some 
subjects there occur pains or disagreeable sensations 
in one or more of these zones, preceding an attack, 
thus simulating the epileptic aura. 

This brief description of the disturbances of sen- 
sation met with in hysteria — namely: anesthesia, 
paresthesia, and hyperesthesia — show T s us that the first, 
or anesthesia, is the most common, and follows a more 
regular course of distribution than the other two 
varieties. Paresthesia is not very well defined, and 
is often not to be differentiated from anesthesia on 



SYMPTOMATOLOGY. 95 

the one hand and hyperesthesia on the other. Hy- 
peresthesia, while not as characteristic a stigma as 
anesthesia, is very generally present in hysteria, and 
has associated with it that very peculiar and little 
understood phenomenon of hysterogenesis. 

The three illustrative cases mentioned above — 
and many more could be cited from the writer's ex- 
perience — are valuable in confirming the fact of 
hysterogenesis as originally enunciated by Charcot, 
since none of these subjects could possibly have 
known the meaning of the pressure upon certain 
spots. I refer to this especially because the pheno- 
menon of hysterogenesis has been doubted, and it 
has been alleged that the phenomena were the result 
merely of suggestion. 



CHAPTER IV. 

DISTURBANCES OF MOTION: TREMOR, 
CONTRACTURE, PARALYSIS. 

In studying the sensory disturbances of hysteria, 
a very formidable difficulty presents itself in the fact 
that the symptoms are purely subjective. The 
patient declares that sensation is perverted or lost, 
and the statement must be accepted, since there are 
no means of proving or disproving such a statement 
absolutely. There are no associate symptoms, such 
as are present in anesthesia from cord or nerve 
lesion. This same difficulty exists, and is on the 
whole more pronounced, in dealing with hysterical 
disturbances of motion. In organic paralysis the 
associate symptoms, such as loss or exaggeration 
of the reflexes, muscular atrophy, alterations in 
the response to the electric currents, and so forth, 
tell the story for diseases of the cord ; and if to these 
symptoms we add the sensory disturbances and 
pain following the course of the diseased nerves, the 
history of the case, the form of the paralysis, the 
eye symptoms in brain disease, the picture of some 
organic lesion is fairly distinct. In hysterical motor 
disturbances, on the other hand, there is only the 
bald statement of the patient. No symptoms pre- 
sent themselves to confirm the patient's statement 

that paralysis exists — the motor disturbance by no 

9 6 



DISTURBANCES OF MOTION. 97 

means always conforms to any organic lesion — and 
the appearance of the affected parts stands as con- 
tradictory evidence against the patient's word. And 
vet a careful study of such cases will always, or 
ought always, convince the physician of the truth of 
what the hysterical subject says in regard to these 
symptoms. The limb cannot be moved, the con- 
tracture cannot be overcome under any ordinary 
stimulus. Let this stimulus, however, be abnormally 
strong — some sudden and intense emotion — and the 
hysterical paralytic becomes as active as ever. In 
other words, the motor apparatus is unimpaired, 
but the power to put this mechanism into action is 
wan tin P". 

All these facts are in harmony with the theory 
advanced in another chapter ; namely, that the lower 
centers are not involved, or only slightly involved, 
in hysteria, while the higher centers, or centers of 
volition, are at fault. An explanation of the fact 
that these higher centers can be aroused by a stim- 
ulus of great intensity is offered in the assumption 
that the protoplasm of the cells composing these 
centers has been expended in great part, and hence 
it requires a very strong stimulus to excite what 
might be called the residual or reserve protoplasm. 

Disturbances of motion naturally fall into four 
categories: (i) Tremor. (2) Contracture. (3) 
Paralysis. (4) Convulsion. It would, perhaps, be 
more in accordance with physiological teaching if 
the arrangement placed tremor and convulsion in 
one class, and contracture and paralysis in another. 
9 



98 HYSTERIA : ITS NATURE AND TREATMENT. 

Slight disturbance of the motor apparatus, or over- 
use of it, occasions tremor ; sometimes due to a 
central lesion, sometimes to muscular fatigue. If 
the irritation be carried further, convulsive move- 
ments result, with perhaps more or less contracture 
remaining, and the final stage is paralysis. For pur- 
poses of convenience the arrangement given above 
will be followed, except that the convulsive attack 
will be described in a special section. 

Tremor. — A symptom that has not attracted 
much attention, but one that is usually present in 
hysteria, is tremor. It is one of the stigmata of the 
interparoxysmal state. It may involve the whole 
body, or be confined to one side — the hemiplegic 
form — or even show itself in but a single limb. The 
movements are of slight range, and vary in fre- 
quency from four to ten oscillations per second. 
Modifying the classification of Charcot and Dutil, 
there are two distinct varieties of hysterical tremor : 
( i ) Tremor persisting during repose and very slightly 
affected by voluntary movements. The oscillations 
are sometimes comparatively slow, three to five per 
second, or more rapid, eight to nine. (2) Tremor 
which may or may not be present during repose, but 
which is greatly exaggerated by voluntary move- 
ments. The number of oscillations in this form of 
tremor range from five to seven per second. The 
first variety may be compared to, and indeed often 
closely resemble, the tremor of exophthalmic goiter, 
alcoholism, mercurial or senile tremor ; the second 
variety simulates the intention tremor of multiple 






DISTURBANCES OF MOTION: TREMOR. 99 

sclerosis. Tremor is not as constant or as charac- 
teristic a symptom as anesthesia, but is present in 
some degree in most cases. It would seem to be 
especially common in men and children. Usually 
its mode of onset is sudden, especially following 
same traumatism or shock. Perret* relates the case 
of a girl, aged eleven, in whom the tremor began 
suddenly after a fright. The whole body was in- 
volved, and the severity of the tremor was such that 
it interfered with the use of the hands. Gilles de la 
Tourettef mentions several cases in which the hand- 
writing was greatly altered by hysterical tremor. 
It is probable that all the cases of distinct rhythmic 
chorea should be included under the head of hys- 
terical tremor. While hysterical tremor is usually 
associated with other stigmata of the disease, it is 
certainly quite often seen in mild cases of hysteria, 
particularly mental hysteria where the somatic stig- 
mata are absent or very slightly marked. The 
duration of hysterical tremor, like most of the inter- 
paroxysmal symptoms of hysteria, is very variable. 
Some cases last but a few months, while others will 
extend over years. The tremor becomes most 
marked after an attack, and pressure upon the hys- 
terogenic zones will generally intensify the move- 
ments. The relation between hysterical tremor and 
certain metallic tremors has attracted attention. In 
some instances it would seem that such poisons as 
lead and mercury predispose to hysteria, and that 

* Lyon Med. , Sept. ,1891. f Op. cit. 



ioo HYSTERIA: ITS NATURE AND TREATMENT. 

the tremor seen in these cases was not due to the 
metallic poison but was hysterical in nature. 

Contracture. — Contracture is a more pronounced 
and characteristic symptom of hysteria than the one 
just described, tremor, though much less common 
than anesthesia. The older writers, such as Briquet,* 
Brodie,*j" and Duchenne, J while noting the existence 
of contracture, described very few cases. Charcot § 
and his pupils have carefully studied the whole ques- 
tion, and have added greatly to the clinical picture. 
Charcot, especially, calls attention to what he calls 
the contracture diathesis. This curious neuromus- 
cular state does not manifest its presence by any 
objective sign, as Richer || points out, and the person 
affected has free use of the muscles. The contrac- 
ture is provoked by massage of the muscles, blows 
on the tendons, sudden flexion of the limbs, faradiza- 
tion of muscle or nerve, and other stimuli. The 
tendon reflexes are usually considerably heightened, 
and electrocontractility is modified. This modifica- 
tion, as was first shown by Richer, consists, for the 
main part, in a tendency of the current to spread ; 
that is, to cause contractions of other groups of 
muscles than the one directly excited by the current. 
The contracture diathesis resembles the hypnotic 
state in many of its features, and it is probable that 
many of the phenomena observed are due entirely 
to suggestion. Contracture is most frequently ob- 



* Op. cit. f Op. cit. \ " De P Electrisation Localisee." 

| Op. cit. || " Paralysies et Contractures Hysterique," Paris, 1892. 



DISTURBANCES OF MOTION: CONTRACTURE. 101 

served after a convulsive attack, though it is a com- 
mon interparoxysmal symptom. When not directly 
preceded by an attack of grand hysteria it can usu- 
ally be traced to some exciting cause, such as trau- 
matism, neuralgic pain, fright, and the like. The 
tendency of contracture to follow very trivial injuries 
makes it worthy of careful consideration. While 
occasionally contracture may develop gradually, fol- 
lowing amyosthenia, paralysis, or spasmodic seizures, 
as a rule its appearance is sudden. An hysterical 
patient has had a convulsive seizure, and upon 
regaining- consciousness contractures of one or more 
limbs are seen. The grand attack passes like a tor- 
nado, and leaves ereater Q r less destruction in its 
wake, now paralysis, now contracture ; changing the 
nature or degree of the interparoxysmal symptoms, 
or adding new ones. 

It is to be noted that the contractures attributed 
to traumatism rarely follow any grave injury. A 
slight cut or burn, a blow causing no apparent in- 
jury, a fall, are some of the common causes. Con- 
tracture is very liable to follow an injury attended 
with emotional circumstances, especially if there is 
an added suggestion. In traumatic cases the seat 
of the injury determines, in a general way, the ex- 
tent and location of the contracture. Contracture 
may affect only part of a muscle bundle, giving rise 
to what Weir Mitchell calls a muscular tumor, or 
it may involve wide-spread groups of muscles. 
Again, while usually attacking voluntary muscles, 
it is not uncommon to see involuntary muscles 



102 HYSTERIA: ITS NATURE AND TREATMENT. 

affected, as, for example, the contracture of the in- 
testines. A convenient classification of hysterical 
contracture is that given by Axenfeld and Huchard.* 
With some modifications it is as follows: (i) Con- 
tracture following the monoplegic type, in which a 
single limb is involved. (2) The paraplegic type, 
in which both lower limbs are affected, either simul- 
taneously or one after the other. (3) The hemi- 
plegic type. (4) The crossed form, the leg on one 
side and the arm on the other. (5) The rare gen- 
eral form, in which all four extremities are involved. 
(6) The periarticular form, in which the muscles 
about the joints are affected. (7) The irregular 
form, under which might be classed certain partial 
contractures, such as torticollis, and the facial mus- 
cles, and also involuntary muscles. In the mono- 
plegic form the leg is the most frequent seat of the 
affection, according to the French school. Gowers f 
thinks that the arm is affected oftener than the 
leg. In contracture of the upper extremity the 
fingers are strongly flexed on the palm. They may 
be flexed at the metacarpophalangeal joints and 
extended at the phalangeal. The wrist is usually 
strongly flexed, and the forearm is flexed upon the 
arm, and either pronated or supinated. Sometimes 
the hand alone is involved, or even one finger. 
The following case illustrates the monoplegic type 
in the upper extremity : An intelligent sailor had a 



* " Traite des Nevroses. " 

f •' Diseases of the Nervous System.' 



DISTURBANCES OF MOTION: CONTRACTURE. 103 

fall on board ship, and shortly after came under my 
care at the City Hospital. A most careful examina- 
tion failed to reveal any injury whatever about the 
shoulder or arm. Immediately after the fall the 
arm was contractured, and when admitted into the 




Fig. 8. Fig. 9. Fig. 10. 

Forms of Contracture of Hand and Wrist. — [After Richer.) 

hospital he was entirely unable to use it. His 
fingers were strongly flexed, at both metacarpo- 
phalangeal and phalangeal articulations ; the wrist 
was flexed on the forearm and the latter strongly 



104 HYSTERIA: ITS NATURE AND TREATMENT. 

flexed on the arm. If great force were used, the 
contracture would change its form, but could not be 
overcome. The usual position of the arm was 
flexion of the forearm on the arm, pronation of the 
forearm, and adduction of the arm. When a forci- 
ble attempt was made to overcome the contracture 
the position of the parts changed ; the forearm sud- 
denly became strongly supinated, the wrist ex- 
tended, and the arm abducted. 

In contracture of the lower extremity the leg is 
forcibly extended. Charcot,* in describing a typical 
case, says : " The left lower limb is in a state of exten- 
sion ; the thigh is strongly extended and also the leg ; 
the foot shows marked equinovarus. All the adduc- 
tor muscles of the thigh are rigid, all the joints fixed, 
and the limb as a whole is like a bar of iron." He 
regards this as the characteristic position, and con- 
siders flexion of the lower limb as exceptional. 
Other writers seem also to regard the occurrence of 
flexion of the leg as rare. The following case is an 
instance of flexion of the lower extremity : Mary Y., 
aged thirty-five, profoundly hysterical for years. She 
exhibited, during the time she was under my obser- 
vation, nearly every recorded stigma of hysteria, from 
anesthesia to ischuria. The left leg was strongly 
flexed on the thigh and the thigh upon the abdomen. 
This contracture had lasted for a year at least, and 
probably somewhat longer. The whole of the leg, 
and in fact the entire left side, was anesthetic. The 

* Loc. cit. 



DISTURBANCES OF MOTION : CONTRACTURE. 



105 



contracture was readily cured by suggestive treat- 
ment. 

The hemiplegic form of contracture involves the 
arm and leg of the same side, the arm being usually 
flexed and the leg extended. 
The left side is more often af- 
fected than the right. Usually, 
both extremities are involved 
simultaneously, though the con- 
tracture may attack first one 
and then the other. As this 
form of contracture not infre- 
quently follows hysterical par- 
alysis, it is necessary to dis- 
tinguish between hysterical and 
organic contraction. This is, as 
a rule, not difficult, since the 
contraction of secondary de- 
generation is very gradual in 
its onset. Other points of dif- 
ference will be noted in the 
chapter on Differential Diag- 
nosis. 

In the paraplegic form of hys- 
terical contracture the legs are 
both extended and adducted. It 
appears after a convulsive attack, or follows paralysis 
of the lower extremities. Rare cases are reported of 
contracture of all four extremities, but this is generally 
a transient condition, in which first one then the other 
side is involved. The periarticular form of con- 




Fig. 11. — Contracture of 
the Lower Extremity. 
—{After Richer) 



io6 



HYSTERIA: ITS NATURE AND TREATMENT. 



tracture may simulate very closely some of the vari- 
eties of talipes, especially equinovarus, and, as has 
been pointed out elsewhere, contracture of the mus- 
cles about the hip-joint has not infrequently been 
mistaken for coxalgia. Besides the varieties of con- 





Fig. 12. — Hysterical Contracture of 
the Foot : Equinovarus Type. — [After 
Richer S 



Fig. 13. — Contracture of 
Foot without Con- 
tracture of the Toes. 
— {After Richer.) 



tracture mentioned above, involving the muscles of 
the trunk and extremities, it is not uncommon to see 
contractures of the facial and ocular muscles, of the 
laryngeal muscles, of the esophagus, vulva, stomach, 



DISTURBANCES OF MOTION: CONTRACTURE. 107 

intestines, etc. Contracture of the facial muscles, 
simulating facial paralysis, not infrequently occurs 
after a convulsive attack. Contracture of the mus- 
cles of the lower jaw, giving rise to hysterical teta- 
nus, is not rare. The following cases* are illustra- 
tive : A negress, under my care at the City Hospital, 
with marked hysterical stigmata, showed, after each 
convulsive attack, rigid contracture of the temporal 
and masseter muscles, lasting for several hours. 
No other muscles of the body were affected with 
contracture, and there was no paralysis. 

In another case, also a negress, the hysterical at- 
tack came on after a slight traumatism. After the 
convulsive seizure the jaws remained so tightly 
clenched that it became impossible to feed her. She 
was cured by suggestion. 

A more persistent case was that of a young white 
woman, with general hysterical symptoms and his- 
tory, but presenting no stigmata other than con- 
tracture of the muscles of the jaw. This condition, 
which had lasted for a week, and which prevented 
her from taking any but liquid food, w T as readily 
cured by suggestion. Contracture also affects the 
muscles of the eye, and while the cases are not per- 
haps very frequent, still enough authentic and care- 
fully observed instances have been reported to show 
that the muscles of accommodation may be involved, 
causing, as Galezowski, Parinaud, Borel, and others 
have pointed out, a true hysterical myopia or hyper- 

* Jour. Amer. Med. Assoc, Jan., 1 894. 



108 HYSTERIA: ITS NATURE AND TREATMENT. 

opia. In like manner the muscles moving the eye- 
ball may be the seat of hysterical spasm or con- 
tracture, causing strabismus, diplopia, and other 
muscular defects. More common still rs hysterical 
blepharospasm, which may be unilateral or bilateral, 
and ptosis is also met with. Hysterical contracture, 
as has been noted, does not spare involuntary mus- 
cle. It is most probable that the classic symptom, 
globus hystericus, is, in part at least, a contracture. 
Some patients describe this peculiar phenomenon as 
a ball which begins in the region of the stomach and 
rapidly ascends to the throat. When it has reached 
the throat it remains a greater or less length of time 
in that position. Rarely, the ball seems to descend. 
Sometimes there is the sensation of a very small 
body in the throat, and again merely a sense of con- 
striction. While, perhaps, a large part of this phe- 
nomenon is purely psychic, and belongs to the cate- 
gory of sensory disturbances, it is probable that there 
is present more or less contracture of muscle fiber. 
From this symptom probably came the old idea 
(chap, i) that in hysterical attacks the uterus slipped 
from its moorings and wandered to the throat. 

Contractures of the stomach and intestines have 
been mentioned. Contracture of the bladder, with 
retention of the urine, is not uncommon. In hysteri- 
cal vaginismus there is muscular contraction as well 
as hyperesthesia. Contracture of the muscles of 
the abdomen and intestines gives rise to the well- 
known " phantom tumors." Contracture, or rather 
spasm, of the diaphragm sometimes occurs, as in 



DISTURBANCES OF MOTION: CONTRACTURE. 109 

the case of a young man apparently healthy who 
presented himself at my clinic With this symptom. 
Every one or two minutes there would be a violent 
contraction of the diaphragm, interfering somewhat 
with respiration ; the case was speedily cured by 
suggestion. Hysterical spasm of the larynx is some- 
times seen, both inspiratory and expiratory, occasion- 
ing cough or modification of the voice, and interfer- 
ing more or less with respiration. In addition to 
this, the common form of contracture, Richer calls 
attention to another variety in which there is severe 
pain at the seat of contracture. While, of course, 
any muscles may be involved in hysterical contrac- 
ture, the varieties given above are the ones com- 
monly seen. 

Hysterical contracture, as has been noted, almost 
always comes on suddenly, and generally follows a 
convulsive seizure or traumatism. The muscles are 
very rigid, and it is generally impossible to overcome 
the contracture by force, though often the form of 
the contracture may be altered. The reflexes are 
not greatly changed, though there is a tendency to 
exaggeration. Charcot has called attention to the 
fact that in some cases of contracture of the leg, 
ankle clonus may be obtained. The electric reaction 
is slightly altered, as was shown in speaking of the 
contracture diathesis. An important fact to be noted 
is that in hysterical contracture, however long the 
time that the limb may have been flexed or extended, 
it rarely happens that any change takes place in the 
joint. 



no HYSTERIA: ITS NATURE AND TREATMENT. 

In one of the cases mentioned above, the left leg 
had been flexed at the knee, and the thigh at the hip- 
joint, for a year or longer. The sister of the patient, 
a very intelligent woman, told me that during that 
time she had never seen the limb extended, though 
she had observed it carefully both day and night. 
Under partial hypnotic suggestion the limb was 
straightened out, and the movements of the joints 
were perfect. On the other hand, in a case in which 
hysterical contracture was suspected, chloroform 
anesthesia failed to produce relaxation, and a diag- 
nosis of non-hysterical contracture was made, which 
was confirmed by an operation upon the diseased 
joint. The slighter forms of contracture relax dur- 
ing sleep, though it will be seen, from the case related 
above, that the more severe cases retain the contrac- 
ture continuously. The administration of chloroform 
or ether is practically a perfect test, since it rarely, 
if ever, happens that complete relaxation does not 
follow profound narcosis. Nutrition is not greatly 
affected, though in long-continued cases there may 
be slight general atrophy from disuse. This, how- 
ever, is never as marked as the atrophy which fol- 
lows the disuse of a limb subsequent to fracture. 
Perhaps, in certain rare cases, some degeneration 
may take place involving the cord, and Charcot has 
put on record an instance of this. In the case 
referred to, a hysterical contracture, which at first 
was intermittent, finally became permanent, and an 
autopsy revealed a sclerosis of the lateral columns 
of the cord. It must be admitted that the notion 



DISTURBANCES OF MOTION : PARALYSIS. ill 

of degeneration following hysterical contracture is 
based very largely upon this single case. It is diffi- 
cult to determine whether there is loss of strength 
in the contractured muscles, but it would seem that 
this is generally the case. The association, as we 
have seen, is very close between contracture and 
paralysis, one often following the other. Certain it 
is that there nearly always exists an anesthesia, 
which may involve the entire side or only the con- 
tractured muscles. This can nearly always be dem- 
onstrated, even in cases of very limited contracture 
— as, for example, blepharospasm — and constitutes 
a valuable diagnostic sign. 

The duration of hysterical contracture cannot be 
fixed; it may last days, months, or years. It may 
be continuous, or complete remissions may occur. 
The disappearance of hysterical contracture, like its 
onset, is usually sudden. It may cease without 
obvious cause, or be cut short by suggestive treat- 
ment, hypnotic or non-hypnotic, by the faradic cur- 
rent, or some sudden, intense emotion. 

Hysterical Paralysis. — Loss of power, or loss 
of control over the muscles, is a very common 
symptom of hysteria, and has been recognized since 
the days of Hippocrates, in whose writings can be 
found a very clear description of this symptom. 
Sydenham, Pomme, Brodie, Laycock, and in fact all 
the early writers on hysteria, have described hysteri- 
cal paralysis. In a paper by John Wilson, pub- 
lished in the " Medico-Chirurgical Transactions," of 
London, for the year 1838, there is an excellent 



H2 HYSTERIA: ITS NATURE AND TREATMENT. 

description of some of the varieties of hysterical 
paralysis, and, what is interesting, an outline of'treat- 
ment by seclusion, rest, etc. Briquet met with some 
form of paralysis 120 times in his 433 cases, and 
Landouzy found it 40 times in 370 cases. My own 
experience leads me to think that it is much less 
frequently seen in this country than some of the 
other stigmata. The onset of paralysis may be 
gradual, being preceded by a certain amount of 
muscular weakness or incoordination ; or it may be 
sudden, as in the case of hysterical hemiplegia. 
The paralysis may be entirely an interparoxysmal 
symptom, or, as most frequently happens, may 
appear immediately after a convulsive attack. In 
common with other symptoms, it may take the place 
of some other stigma, occurring on the disappear- 
ance of anesthesia, contracture, or the like. Many 
instances are related of the appearance of paralysis 
after some sudden emotion. Akin to this is the 
paralysis which follows some insignificant injury — 
traumatic hysteria. It is not uncommon to see cer- 
tain mild forms of hysterical paralysis after the 
subsidence of some acute affection ; such, for ex- 
ample, as typhoid fever. It is possible that some of 
the cases reported as post-febrile neuritis are in 
reality hysterical in character. 

The most important of the causes that seem to 
bear upon the production of hysterical paralysis is 
the convulsive attack ; as has been pointed out, 
this is the highest manifestation of hysteria. It is 
the acute attack, and nearly always leaves some 
sequelae. 



DISTURBANCES OF MOTION : PARALYSIS. 113 

Next in importance as an etiological factor is trau- 
matism. It is often difficult to decide between true 
hysterical paralysis and wilful deception, when trau- 
matism has been the exciting cause and a damage 
suit is in prospect. 

Hysterical paralysis varies in degree from slight 
impairment of strength to entire loss of power. It 
is not uncommon to hear hysterical patients com- 
plain of sudden weakness, generally, however, of 
short duration. Sometimes the arm becomes help- 
less, and anything held in the hand will be dropped ; 
or, what is perhaps more common, the weakness at- 
tacks the legs, and the patient falls or has to sit 
down at once. This muscular weakness, to which 
the name amyosthenia has been given, is usually 
hemiplegic in form. When one limb only is involved, 
all the muscles, both flexors and extensors, are 
affected. The most certain way to test this loss of 
power is by means of the dynamometer. Repeated 
tests should be made, comparing the affected with 
the sound side, and recording the results for future 
reference. In order that the tests be accurate, the 
patient should not be allowed to look at the index 
while pressing the dynamometer. Passing on to the 
more pronounced forms of motor disturbance, we see 
all varieties of paralysis. The most common type is 
the hemiplegic, and the attack, which usually pre- 
cedes the onset of the paralysis, resembles in some 
degree an ordinary apoplexy. It may come on sud- 
denly or gradually, and with or without loss of con- 
sciousness. Sometimes instead of an attack the 



U4 HYSTERIA: ITS NATURE AND TREATMENT. 

patient sinks into a profound sleep, and the paralysis 
appears after awakening. The left side is more fre- 
quently involved than the right. When the attack 
comes on gradually one limb is first involved, and 
after a greater or less length of time the other limb 
becomes affected ; sometimes it is the lower limb 
that suffers first, again the upper. The paralysis is 
generally more marked in the lower than in the upper 
extremity. When the paralysis is only of moderate 
degree, and the patient able to walk, the paralyzed 
foot is dragged and not swung outward in a half 
circle as is seen in organic hemiplegia. As Rey- 
nolds* remarks, the hysterical patient looks at the 
observers when attempting to walk, and not at the 
ground, as the true hemiplegic does. 

The face is rarely ever involved in hysterical hemi- 
plegia. Until very recently it was stated that this 
was invariable, and a valuable diaenostic sign. 
Thus Axenfeld and Huchard, Gowers, Dana, and 
most authors state that the face is never affected, 
and Charcot formerly held this same view. In the 
last three or four years, however, several cases of 
undoubted hysterical hemiplegia, accompanied by 
facial paralysis, have been reported. Ballet f refers 
to three cases noted by Chantmesse, and relates one 
case of his own. It was formerly taught, especially 
by Charcot, that what appeared to be facial paralysis 
was in reality contracture, and that the movements 



* " System of Medicine." 
j- L ' Un ion Med. , 1890, 



DISTURBANCES OF MOTION: PARALYSIS. 115 

of the apparently paralyzed side were impaired solely 
by the strong contracture of the opposite side. It 
must be admitted that while facial paralysis is a very 
infrequent accompaniment of hysterical hemiplegia, 
still it does sometimes occur. 

While, as has been said, hysterical paralysis may 
be absolute, this is far from common. Usually the 
loss of power is only partial, and the patient will 
be able to drag the limb or slightly raise the arm. 
The deep reflexes are normal or slightly exaggerated, 
and sometimes, though rarely, ankle clonus can be 
obtained. The superficial reflexes are often lost, 
since hysterical hemiplegia is so often associated 
with an anesthesia of the same side. The electrical 
reactions are practically unaltered. A negative sign 
of value, and one that was noted when speaking of 
contracture, is the entire absence of any nutritive 
changes even in long-continued cases of hysterical 
hemiplegia. The skin is natural and the muscles 
preserve their plumpness. To this rule there may 
be rare exceptions, as will be seen in another 
chapter. 

Associated with hysterical paralysis are to be found 
many of the other stigmata of the disease, hyper- 
esthesia, pain, anesthesia, contracture, and the like ; 
anesthesia is nearly always present, and generally 
corresponds to the paralysis ; for example, if only 
one limb is paralyzed, the anesthesis is usually lim- 
ited to the part involved. This is, of course, not an 
absolute rule, since the anesthesia may be dis- 
seminated. 



n6 HYSTERIA: ITS NATURE AND TREATMENT. 

Next in frequency to the hemiplegic is the para- 
plegic form of paralysis. Gowers believes that this 
latter variety is the most common, and my own ex- 
perience leads me to the same conclusion. The most 
characteristic form of hysterical paraplegia is the 
sudden giving way of the limbs noted above. The 
duration of the paralysis in this case is, as a rule, 
short, and there is only moderate loss of power. In 
a more advanced degree there may be absolute loss 
of motion in the lower extremities. The reflexes 
are, as in the hemiplegic form, normal or exagger- 
ated, and this being associated with anesthesia in the 
great majority of cases furnishes a valuable diagnos- 
tic point between hysterical and organic paraplegia. 
The electrical reactions are unchanged, and nutrition 
is very slightly, if at all, affected. The most common 
cause of hysterical paraplegia is traumatism, and the 
rapid transit street railways are daily furnishing ex- 
amples of this form of hysteria. As will be seen in 
another chapter, the nature of the paralysis, and the 
fact that the accompanying anesthesia does not cor- 
respond with the supposed cord injury, generally 
makes the diagnosis clear. 

Monoplegias are very common, affecting an entire 
limb, or only certain groups of muscles. Monople- 
gia, like paraplegia, is very often traumatic, and is 
generally accompanied by anesthesia. 

Quadriplegia, or paralysis of all four extremities, 
is not common, though a number of such cases have 
been reported. 

Hysterical aphonia, due to paralysis of the vocal 



DISTURBANCES OF MOTION: PARALYSIS. 117 

cords, is quite common. It is necessary to distin- 
guish between this and hysterical mutism, a very 
different condition. Often some emotional cause is 
responsible for the onset of the paralysis, or again 
it sometimes seems to be excited by a slight cold, or 
an unimportant throat affection. The vocal cords 
are widely separated by paralysis of the adductor 
muscles. While this is the rule, it occasionally hap- 
pens that the abductors are involved. In both cases 
the paralysis is, as a rule, bilateral. In the case of 
an elderly man referred to me there was paralysis 
of only one adductor muscle. As there were very 
few other stigmata present, the case was for a time 
puzzling, until subsequent developments showed the 
nature of the affection. 

The mucous membrane of the larynx shows 
nothing abnormal. There always exists more or 
less anesthesia ; this may amount to only a trifling 
lowering of sensibility, or there may be total anes- 
thesia. When I was a student at the Salpetriere 
this was generally regarded as a valuable symptom of 
hysteria, and anesthesia of the mucous membrane 
was found to be present in nearly all cases of hys- 
teria. My experience with hysteria in this country 
has not shown this symptom to be nearly as common 
as in the French cases. Patients affected with hys- 
terical aphonia can generally use low notes, and 
often are able to sing. The duration of hysterical 
aphonia is uncertain ; in one of my cases it lasted 
for two or three years, and Gowers mentions a case 
which continued, with occasional brief intermissions, 



n8 HYSTERIA: ITS NATURE AND TREATMENT. 

for ten years. The paralysis generally disappears 
as suddenly as it comes on. This sudden onset and 
equally sudden subsidence of symptoms are points 
of such great value in the differential diagnosis of 
hysteria, that it cannot too often be referred to. 

In addition to paralysis of the muscles of the 
larynx, we sometimes meet with paralysis of the 
pharynx and esophagus interfering with deglutition. 
There is a sense of constriction, and food taken 
lodges midway down the esophagus, sometimes in- 
terfering with respiration. There is at present under 
my care a young negro girl who, for a year or more, 
has not been able to swallow any solid food, or at 
least anything but the very smallest particles. She 
breaks up her bread into minute crumbs, and any 
attempt to swallow large particles produces regur- 
gitation. Careful examination has failed to reveal 
any lesion of the esophagus, and a large esopha- 
geal bougie passes without difficulty. These cases, 
while at first sight alarming, never cause any serious 
disturbance. The enormous distention of the stom- 
ach and intestine with gas, so common in the course 
of hysteria, is not easy to explain. Some writers 
claim that it is produced by swallowing large quan- 
tities of air. It would sometimes seem to be the re- 
sult of contracture, and sometimes of distinct paraly- 
sis of the muscle of the intestine. It is clear that 
it is not caused by decomposition of food material 
in the stomach or intestines. This symptom was a 
marked feature in some of the epidemics of hysteria 
that were seen in the middle ages (see chap. i). 



DISTURBANCES OF MOTION: PARALYSIS. 119 

Joly* makes the rather remarkable statement 
that in some instances this inflation was so great 
that the patients would float in water. In some 
cases of enormous distention respiration may be in- 
terfered with. Paralysis of the bladder is not un- 
common, and a few cases of paralysis of the dia- 
phragm have been reported. 

While contracture of the various muscular struc- 
tures of the eye is very common, paralysis is so rare 
that it can almost be disregarded. Pansier,-)- in a 
careful review of all the literature, has been able to 
collect only a few cases, and some of them doubtful, 
of hysterical paralysis of either extrinsic or intrinsic 
muscles. A few instances of hysterical paralysis 
of the third and sixth nerves have been recorded. 
Ophthalmoplegia would seem to be met with occa- 
sionally, as are cases of paralysis of the muscles of 
accommodation, and paralysis of the iris. 

We are unable to explain why it is that, while con- 
tracture of the muscles of the eye and sensory dis- 
turbances of vision are among" the common manifes- 
tations of hysteria, paralysis should be so rare as to 
raise the question whether it really exists. 

Besides the conditions discussed above of muscu- 
lar weakness or paralysis, there is very often present 
in hysterical subjects a certain amount of muscular 
incoordination. Reynolds says the voluntary move- 
ments are sluggish,- irrational movements are in ex- 



*Ziemssen's Cyclopedia, 
f Op. cit. 



120 HYSTERIA: ITS NATURE AND TREATMENT. 

cess, and emotional movements are exaggerated. 
There seems to be a loss of control over the mus- 
cles, sometimes wide in extent, again confined to 
certain groups of muscles only. In some cases, 
though certainly not in all, this may be due to loss 
of muscular sense. Among the various forms of 
muscular incoordination seen in hysteria there is a 
symptom complex which has been dignified by the 
French school with the name astasia-abasia. This 
condition, seen most frequently in children, consists 
of an inability to maintain the erect position, with, 
sometimes, tremor or choreiform movements. When 
the patient lies down the legs possess their normal 
strength, but as soon as an attempt to stand or walk 
is made, the patient falls, or walks in a most gro- 
tesque, irregular manner. Rigidity is sometimes 
present in these cases. The reflexes are unaltered, 
and there is no disturbance in the electric reactions, 
nor is the nutrition of the parts interfered with. 
The termination is either in a sudden cure, or in 
a change to some other hysterical phenomenon. 
Looked at as a whole, hysterical paralysis occurs, 
with few exceptions, along with other distinct hys- 
terical stigmata. Its onset is sudden, and frequently 
traceable to some emotional cause, or determined by 
a trauma or other suggestion. The distribution of 
the paralysis is not in accord with a spinal or peri- 
pheral lesion, now involving one-half of the body, 
now part of a limb, causing hemiplegia, paraplegia, 
monoplegia, or quadriplegia. The paralysis is rarely, 
if ever, complete. It is very generally attended with 



DISTURBANCES OF MOTION : PARALYSIS. 121 

anesthesia ; the reflexes are practically unaltered, 
nutrition unimpaired, electric reactions unchanged. 
In other words, the symptoms point almost with cer- 
tainty to the cortical centers for their origin. The 
course of the paralysis, like all other symptoms of 
hysteria, is extremely irregular and uncertain, now 
lasting for a few days, again being prolonged for 
months or even years. 



CHAPTER V. 

CONVULSIVE ATTACKS: MAJOR AND MINOR 
ATTACKS.— HYSTERO-EPILEPSY. 

Among the multiform symptoms of hysteria, the 
one which, take it all in all, is most characteristic is 
the convulsive seizure. As has been pointed out in 
a previous chapter (chap, i), the hysteria of the middle 
ages seemed especially prone to manifest itself by 
convulsive movements. Among uncivilized, or semi- 
civilized, peoples, recognizing no reason for con- 
straint, emotions at once find outward expression. 
Fear, anger, love, reverence, are all visibly depicted 
on the countenance, and graphically represented by 
gestures. The epidemics of the middle ages, refer- 
red to above, were characterized by wild, grotesque, 
lascivious, devotional, and other gesticulations. 
Among the negroes of the Southern States of 
America convulsive attacks are more common than 
among the whites, and are seen oftener than other 
stigmata. With civilization comes the cultivation of 
a conventional restraint, the development of a cer- 
tain center which in the savage state was rudimen- 
tary. If this supposed center becomes functionally 
impaired, then, there being no check, no control, the 
natural impulse to express emotion of any kind by 
bodily movement obtains. According as the function 
of these centers is impaired or totally abolished, will 



CONVULSIVE ATTACKS. 123 

there be now a mere increase of the natural tendency 
to express emotion by gesticulation, now a wild, in- 
coherent, grotesque exaggeration of these gestures. 
The first of these states is recognized by, and familiar 
to, the laity. The popular idea of hysteria is derived 
from the observation of these well-known pheno- 
mena, and hysteria without them is not understood. 
After some sudden emotion, either pleasurable or 
the reverse, an exciting dance, some unexpected 
stroke of good fortune, a sudden fright, the receipt 
of unwelcome news, the hysterical girl bursts into an 
uncontrollable fit of laughter, which generally alter- 
nates with weeping. She throws her arms about, 
pulls down her hair, throws herself on the floor, 
sings, makes grimaces, embraces the bystanders, or 
expresses fear or distrust of them. Quickly the 
various emotional phases succeed one another, joy, 
fear, anger, remorse, accompanied by the gestures 
appropriate to each state. 

After a period varying from minutes to hours, the 
storm is followed by a calm, the period of excitement 
is succeeded by one of depression. During this mild 
paroxysm there may be apparent hallucinations, 
generally visual. The identity of the persons about 
the patient is not infrequently confused, and while 
consciousness is disturbed it is not lost. Sometimes 
the attacks are largely mental with few physical 
manifestations, but as a rule there is present more 
or less movement. Generally this is confined to 
gesticulation expressive of some emotion, folding the 
hands in supplication, doubling the fist in anger, 



124 HYSTERIA: ITS NATURE AND TREATMENT. 

wringing the hands in despair, and the like. There 
is usually present some muscular rigidity, a mere 
premonition of what is to follow in the severe attacks. 
It is to be noted that in these mild attacks the indi- 
viduality of the patient modifies to a greater or less 
degree the symptoms. This is to be expected when 
we observe that consciousness is not entirely lost in 
these ligrht attacks. In this form the movements of 
the limbs are in large part voluntary. If the patient 
is lying on her back on the bed or floor, she will 
kick her feet violently, and throw her arms about 
in a distinctly purposive manner. Quite often she 
will seize some one standing near. Efforts at for- 
cible restraint will markedly increase the violence 
of the movements. As a rule, there is no disturbance 
of the circulation or respiration. The pulse is not 
increased more than the active exertion would war- 
rant, and if there is no great amount of exertion 
it remains quite normal. The respiration is normal, 
except in certain cases of " hysterical rapid respira- 
tion." In these cases respiration becomes very quick 
and shallow. The face is neither pale nor congested. 
There is a peculiar and rather characteristic quiver 
of the eyelids when the eyes are closed, and this 
sign is of considerable diagnostic value. The pupils 
show no constant or characteristic change. As has 
been said, this minor attack may last from some min- 
utes only, to several hours, and at the close of the at- 
tack the patient may be a little depressed, or in some 
cases appear quite normal. There are no very distinct 
prodromes preceding the attack, which, as has been 



Plate 




CONVULSIVE ATTACKS. 125 

noted, can usually be traced to some distinct, though 
often trivial, exciting cause. The symptoms of the 
minor attack vary greatly both in their form and in- 
tensity, which makes it all but impossible to give a 
description that will apply to all cases. 

The "grand attack," or hystero-epilepsy, as it has 
been unfortunately termed, the form that has been 
rendered classic by Charcot's pen and Richer's pen- 
cil, would seem to be of far less frequent occurrence 
in this country than in France, and the same maybe 
said of England (Gowers). The grand attack in 
this country occurs in persons who, as a rule, pre- 
sent stigmata in the interparoxysmal period. There 
are often slight prodromal symptoms for several 
days, such as nervousness, headache, malaise, and 
other indefinite symptoms. It would seem that, like 
the minor attack, there is nearly always some ascer- 
tainable exciting cause. Often this cause is not dis- 
tinctly an emotional one. A slight and unimportant 
injury, some minor ailment causing perhaps a little 
pain, and the like, are quite as often responsible for 
the outburst as some emotional shock. The patient 
falls, occasionally emitting a cry, which, however, is 
not like the epileptic cry, but is a scream or a num- 
ber of rapidly- repeated exclamations. As a rule, 
the patient rather sinks down than falls, and there is 
rarely any injury done in the fall, though this rule is 
not absolute, and should not be relied on for diagno- 
sis as much as. is done, since hysterical subjects will 
occasionally hurt themselves. 

Consciousness is lost, the face is usually somewhat 



126 HYSTERIA: ITS NATURE AND TREATMENT. 

congested, or it may be pale, pulse and respiration 
normal. At first there is a period of tonic rigidity, 
lasting for several minutes and succeeded by irregu- 
lar clonic movements. The clonic convulsions bear 
only a very slight resemblance to the clonic move- 
ments of epilepsy. The range is much wider, and 
they appear far more purposive. In this country 
there is no separation between the clonic convul- 
sions and the period of "grand movements " of the 
French school. Not infrequently the " grand move- 
ments " come on at once, immediately succeeding the 
tonic period. The whole body is thrown violently 
from side to side, the arms and legs are thrown about 
with great force, and the head rolled rapidly. There 
is generally decided opisthotonos ; sometimes the 
body is curved laterally. The tonic and clonic periods 
alternate, and pressure upon an hysterogenic zone 
may convert one phase into another. For example, 
a negro woman was brought into the City Hospital 
totally unconscious, her whole body in a condition of 
rigidity ; pressure upon the ovarian region threw 
her into clonic convulsions, which lasted for some 
minutes, and then the tonic stage came on again. 
The tongue is not bitten, and there is no frothing at 
the mouth. As in the minor variety, there is no 
disturbance of the pulse or respiration, and the tem- 
perature remains normal. The eyes are sometimes 
wide open, at other times closed, and when closed 
show the characteristic tremor of the lids that has 
been mentioned. The pupils are normal as a rule, 
but may be dilated. Generally the eyes are turned 



CONVULSIVE ATTACKS. 127 

up, but they may stare straight in front. The attack 
closes by a display of emotion. The patient will 
cry or laugh, pour forth a tirade of abuse upon the 
physician or some member of the family, talk inco- 
herently, become very affectionate, and possibly show 
mild hallucinations, generally visual. Usually sev- 
eral hours elapse before the mental equilibrium is 
entirely regained. 

In the major attack consciousness is completely 
lost. I have satisfied myself upon this point by 
many observations upon patients brought into the 
hospital. These cases, generally mistaken for epi- 
lepsy, after going through the various symptoms 
detailed above, will regain consciousness and look 
about them with the wildest amazement depicted on 
their countenance. They will be at an utter loss to 
account for themselves, and are frequently greatly 
humiliated at finding themselves in the accident ward 
of a hospital. This point is dwelt upon, because, as 
will be seen, attempts at treatment too often proceed 
upon the theory that the patient is entirely conscious 
of what is going on around her. During the greater 
part of the major attack there is entire loss of cuta- 
neous sensibility. A pin may be thrust through the 
skin without the patient being aware of it, and the 
conjunctiva is insensitive. This is the major attack 
as we see it in this country, though it by no means 
follows with any constancy the very general symp- 
toms indicated above. Sometimes the whole attack 
is tonic, the patient lying in the " crucifix attitude " 
of the French school, with both arms stretched out 



128 HYSTERIA: ITS NATURE AND TREATMENT. 

at right angles from the body, the feet together, the 
eyes open and staring vacantly into space. Again, 
the only characteristic attitude is opisthotonos, which 
will be maintained through most of the attack. 
Other cases show few of these characteristic poses, 
but dash themselves violently about, now starting to 
their feet, now throwing themselves on the bed or 
floor. The inappropriateness of the term hystero- 
epilepsy, as applied to the form of hysteria seen in this 
country, will be apparent from the foregoing descrip- 
tion. There is, of course, a rough general resemb- 
lance — loss of consciousness with tonic and clonic 
convulsions — but the whole course and nature of the 
attack differs in so many essential particulars from the 
grand mal of epilepsy that with any reasonable care 
the two conditions ought never to be confounded. 
Of course, there are cases in which the resemblance 
between epilepsy and hysteria is closer than the symp- 
toms of the latter affection detailed above would 
seem to imply, but these are the exceptions and not 
the rule. A comparison between the two conditions 
will be given in the chapter on Differential Diagnosis. 
It will be seen that the minor and major attacks 
differ only in degree, with often no sharp line divid- 
ing them. In France, the major attack, or grande 
hysterie, is not only a very much more common 
affection, but it presents a far more sharply defined 
and constant symptomatology. I occasionally see 
cases of major hysteria in this country as well marked 
and as characteristic as any I ever saw in the Sal- 
petriere, but these cases are the exception and not 
the rule. 



CONVULSIVE ATTACKS. 129 

Charcot's great work consisted in separating epi- 
lepsy from hysteria, and presenting us with a picture 
which has become classic, of the latter affection in its 
highest development. Grand hysteria has been di- 
vided by the school of Charcot into four distinct pe- 
riods, stages, or phases : (i) The epileptoid. (2) 
The period of grand movements. (3) The period 
of emotional attitudes. (4) The period of delirium. 

The prodromes of an attack may extend over 
several days. The patient generally shows some 
distinct mental disturbance. She becomes very irri- 
table and peevish, is easily provoked to anger by 
trivial causes, gives way to all kinds of emotional 
outbursts. At times she may be boisterous, laugh- 
ing, singing, crying ; again she remains obstinately 
mute. She is unjustly suspicious and jealous; is 
apt to neglect her person, often dressing in some 
bizarre fashion. At times there are hallucinations, 
chiefly visual, occasionally affecting the other senses. 
In addition to these mental symptoms there are often 
distinct somatic prodromata. If the subject have no 
interparoxysmal stigmata, or if these are slight, they 
become prominent and well marked at this time. 
Anesthesia and hyperesthesia are very generally 
present ; the various motor symptoms appear : pa- 
ralysis, contracture, tremor, and the like. The appe- 
tite is lost, or very capricious ; the globus hystericus 
nearly always present ; the abdomen frequently dis- 
tended with flatus. Still nearer the onset of the at- 
tack may appear certain of the characteristic pains 
that have been studied in another chapter, clavus, 



130 HYSTERIA: ITS NATURE AND TREATMENT. 

epigastric or ovarian distress, throbbing sensa- 
tions about the head, and the like, which have some- 
what the value of aurse. These rather indefinite 
symptoms usher in the attack, or at all events usually 
closely precede it. The first period is the epileptoid, 
and it is from this symptom complex that the term 
hystero-epilepsy has arisen. The attack comes on 
sometimes rather gradually, more often suddenly. 
The face becomes pale, the eyes staring, and the 
patient falls to the ground. The fall is rarely as 
sudden or as violent as in true epilepsy. In most 
cases the patient rather sinks to the floor than falls, 
and it is rare that any injury is occasioned by the 
fall. This is due to the fact that consciousness is 
lost more gradually, and the loss is never as complete 
as in epilepsy. There is not heard the characteristic 
" epileptic cry," though there may be some sound — 
sighing, groaning, or exclamation. The whole body 
is now in a state of rigidity — the tonic phase. The 
head is bent back, with, as Richer especially notes, 
marked distention of the throat ; the arms are ab- 
ducted, the fingers clenched on the palm of the 
hand, the le^s and feet extended. There is a ten- 
dency to opisthotonos, and sometimes this condition 
is well marked at this stage. The eyes are gener- 
ally closed, and the pupils, according to Fere, become 
dilated during the clonic phase. There is, in most 
cases, absolute loss of consciousness by the time the 
tonic phase is well developed. The mouth is some- 
times partly open, at other times tightly closed, with 
clenched teeth, and there may be some frothing. 






CONVULSIVE ATTACKS. 131 

The face becomes somewhat congested, and there is, 
perhaps, a slight disturbance of respiration. 

During this period there are tonic movements of 
the limbs, flexion and extension, and movements of 
the trunk. Soon the whole body becomes fixed and 
immobile, assuming some particular position, dorsal 
decubitus, opisthotonos, or the crucifix attitude. 

Immediately succeeding the tonic phase comes the 
clonic period of the epileptoid stage. The move- 
ments are short and quick, though they have not 
the shock-like character of the clonic convulsions of 
true epilepsy. The range of the movements is wider 
than in epilepsy, and they appear somewhat more 
purposive. The body, limbs, and head take part in 
these convulsive movements. Respiration becomes 
somewhat rapid and noisy, and there are movements 
of deglutition. 

The duration of the epileptoid period, or rather 
of the two phases which compose it, is somewhat 
variable, usually occupying from one to five minutes. 
This stormy period is immediately followed by the 
calm of complete muscular relaxation. The subject 
lies motionless, except perhaps a trembling of the 
eyelids. In some cases there is not complete relaxa- 
tion, but contractures more or less pronounced per- 
sist. The duration of this period of relaxation is 
uncertain, generally lasting for a few minutes, and 
then the second phase, or the period of grand move- 
ments, is ushered in. This second stage has been 
variously designated as the period of grand move- 
ments, the stage of contortions, or, as Charcot has 



132 HYSTERIA: ITS NATURE AND TREATMENT. 

happily termed it, the period of clownism. Follow- 
ing the calm that has succeeded the epileptoid move- 
ments, comes the most typical form of the grand 
movements, the phenomenon of opisthotonos, or, as 
the French school term it, the "arc de cercle." The 
body rests upon the back of the head and the heels, 
forming a veritable arch. The muscles of the abdo- 
men are so rigid that a delicate woman can sustain 
the weight of a man sitting upon her, a demonstra- 
tion that all old students of the Salpetriere will recall. 
In this country, my experience has led me to coincide 
with the French school in designating this as by far 
the most common of the forms taken in this second 
period. In the majority of the American cases we 
do not have this absolute opisthotonos, but merely an 
approach to it. Often there is a combination be- 
tween opisthotonos and pleurothotonos, the body 
being curved backward and to one side. After a 
few minutes the opisthotonos gives place to certain 
fairly constant and characteristic movements. Of 
these, perhaps the most common is a rapid flexion 
of the upper part of the body ; the head is thrown 
rapidly forward, nearly striking the knees, and then 
violently back upon the pillow. Quite as common 
in this country is the violent throwing of the whole 
body from side to side. Again, the body may remain 
quiet and the legs be rapidly carried to the vertical 
position and then brought violently down upon the 
bed. These movements of the limbs are usually 
bilateral, but occasionally only one side is involved. 
Sometimes the whole body is raised, resting only on 



Plaie II. 




Fig. i. 




Fig. II. 
The Convulsive Attack — Second period or period of contorsions. 



Fig. 1.— Movements of wide range. 
Fig. 2. — Hystencai Opisthotonos. 



(After R.cher.) 



CONVULSIVE ATTACKS. 133 

the shoulders, so that the feet may almost touch the 
head. These are among the most characteristic of 
the movements seen in this stage, though often the 
contortions are irregular, and do not conform to any 
type. In this phase, we see no movements that are 
in any degree purposive. Every action seems inco- 
ordinate, violent, meaningless. The face generally 
presents a contorted appearance, though the conges- 
tion which was observed in the first stage has dis- 
appeared. In like manner respiration has come back 
to the normal, or nearly so. The duration of this 
second phase is from five to fifteen minutes. As has 
been noted, what corresponds to this stage in Amer- 
ica, is characterized by far more irregular move- 
ments, and as a rule lasts longer. 

The third period is that of passionate attitudes. 
Here we have the most perfect expression of the 
rapidly varying mental states by gesticulation. Just 
as we see in certain conditions of alcoholic intoxica- 
tion, or during the administration of an anesthetic, 
a period in which gesture largely takes the place of 
language, so in this stage of the major attack, when 
certain of the higher centers of the cortex are in- 
capable of performing perfectly their function, the 
lower cortical centers apparently try to make up the 
defect. Thus, in this period, when consciousness does 
not rise quite to the dignity of language, the emotions, 
under no control, are expressed by gestures. Then, 
again, the higher centers are beginning, in this stage, 
to thaw out, as it were, and their action is irregular, 
uneven, and incoordinate. There is hardly any limit 



134 HYSTERIA : ITS NATURE AND TREATMENT. 

to the phenomena of this third stage, since every 
emotion that passes over the disturbed brain is 
represented by its appropriate gesture. One of 
the most characteristic poses is that known as 
the "crucifix attitude." This has been described 
elsewhere. I have satisfied myself that this is not 
the product of suggestion. In two cases seen re- 
cently, both mulatto girls, this attitude was exactly 
as described by the French school, and the subjects 
had never seen other hysterical patients and could 
have had no possible suggestion made to them. 
From the outward expression, we are forced to 
conclude that during this period the patients are 
subject to various hallucinations. They will point 
to objects in the room, or possibly appear to be 
listening to sounds or voices. They are in a sort 
of dream, which rapidly changes the scene from 
grave to gay, from a picture of horror to one of 
delight. The religious beliefs or superstitions often 
enter largely into the dreams, and are portrayed 
by various imitations of religious ceremonies. The 
representation of the various emotional states is 
wonderfully vivid and varied. Fear, anger, menace, 
remorse, sensuousness, and the like, are presented 
with a faithfulness and reality that should be the 
envy of an actor. 

It is clearly impossible to resolve these various 
gestures into any category, or to fix any definite 
period for their duration, as Richer attempts to do. 
For example, he says that the crucifix attitude lasts 
twenty-three seconds ; the attitude of defense, four- 



CONVULSIVE ATTACKS. 135 

teen ; of menace, eighteen ; of appeal, ten ; of luci- 
bricity, fourteen ; of ecstacy, twenty-four ; of dread 
of animals, especially rats, twenty-two ; of listening 
to military music, nineteen ; of scorn, thirteen ; and 
of lamentation, twenty-three. It is obvious that 
while this classification might serve for the Quartier 
Latin, it would not be generally applicable. As has 
been said before, we cannot accept in toto the Sal- 
petriere description of hysteria. 

As will be seen in another chapter, the analogy 
between hysteria and hypnotism, or certain hypnotic 
states, is wonderfully close, and the principle of sug- 
gestion is a factor that must not be neglected. Per- 
sonal experience in the Salpetriere taught me years 
ago that suggestion plays a not unimportant part in 
the symptomatology of the hysteria as described by 
certain pupils of that school. Certain it is that as 
we see hysteria in this country, this third stage is 
never the elaborate and distinct set of symptoms, 
with their regular succession and definite duration 
as certain writers describe. With us this stagfe is 
distinctly emotional and dramatic. Anger, fear, af- 
fection, and so forth, are given outward expression 
by gestures, but they follow no regular order and 
have no definite duration. For example, the case 
of a woman, aged about thirty, who in this third stage 
wept, expressed great affection for the physician, 
whom she had never seen before, with fear of the 
other persons in the room, and a great aversion to 
her husband. This represents the average third 
stage in the majority of cases this side the Atlantic. 



136 HYSTERIA: ITS NATURE AND TREATMENT. 

During this stage the subject may sing or dance, or 
put herself in various suggestive attitudes, and usu- 
ally gives utterance to expressions in harmony with 
the other mental states. Often a very modest girl 
will declare her love for the physician or some by- 
stander, in terms that she would never employ in 
her normal condition, or she may shower epithets 
not usually employed in polite society upon her 
dearest friends. Thus it is seen that this stage is 
essentially the stage of dramatic representation of 
certain emotional conditions. In the preceding 
phase the movements were in no sense purposive ; 
in this third period the gestures represent, with 
wonderful accuracy, the phantasmagoria of the dis- 
turbed brain. 

The fourth period is called the stage of delirium. 
As Richer says, the third phase of the major attack 
is the period of acting ; the fourth stage that of 
speech. Consciousness shows in the third stage a 
dim returning-, and lang-ua^e beine confined to ex- 
clamations, or at most to fragmentary sentences, is 
inadequate to express the emotions, and gestures 
are called to its aid. In the fourth stage conscious- 
ness asserts itself more and more, and speech no 
longer requires the assistance of gestures. Anes- 
thesia has in large part disappeared in the fourth 
stage, and the subject is to some degree conscious 
of the surroundings, though not perfectly so. Hence 
illusions and hallucinations are common. As has been 
noted, these are associated in the main with vision, 
though the other senses may be involved. Long 



CONVULSIVE ATTACKS. 137 

confessions of past experiences are related, gar- 
nished with fanciful details. In the third stage 
hallucinations are probably present, but can be ex- 
pressed only by gestures, while in the fourth, as has 
been said, gesture gives way to speech. A fear of 
animals has been described as a prominent feature 
of the mental state, and the hallucinations often take 
this form. In this stage the motor sequelae of the 
grand attack begin to make their appearance, espe- 
cially contracture. The stage of delirium may be 
indefinitely prolonged, as will be seen when speak- 
ing of the mental condition of hysteria (chap. vi). 

In grand hysteria, as described by many writers of 
the French school, the first stage or phase presents 
practically complete loss of consciousness, and the 
motor manifestations are utterly incoordinate and 
entirely outside the control or even influence of the 
higher centers. In the second stage these move- 
ments become somewhat more purposive, though 
still incoordinate ; in the third stage the muscular 
movements are clearly attempts to illustrate or 
emphasize a mental state that cannot be expressed 
in articulate speech, while in the fourth stage speech 
has returned but the higher centers are not yet able 
to control its wild exuberance. 

In this country, as has already been said, and also 
in England, it is unusual to see these perfect attacks 
of grand hysteria as described by French writers. 
In most of our cases, however, it is possible to dis- 
cern the reflex of this elaborate description. Charcot 
and his pupils describe a form of hysteria as they 



138 HYSTERIA: ITS NATURE AND TREATMENT. 

see it : a disease peculiarly liable to be impressed 
with the characteristic life of the Boulevards in gen- 
eral and the Latin Quarter in particular, and yet we 
must frequently be surprised at the appearance of 
these phenomena that seem to be " suggested symp- 
toms." In my own experience I have often been 
struck with the similarity between the cases of 
hysteria in negroes who, of course, have never been 
in any possible manner under the influence of sug- 
gestion, and the so-called " show cases " at the Sal- 
petriere. It has seemed to me that the genius of 
Charcot has given us a typical picture, with all the 
minutest details, and that while hysteria in this 
country falls short in many respects of his descrip- 
tion, still the type is there, and the differences can be 
accounted for by the diversity in race, climate, edu- 
cation, mode of life, and all the circumstances that 
go to make up the " environment." 

According to Richer, whose description has in the 
main been followed in the foregoing chapter, the epi- 
leptoid period lasts from one to three minutes, sepa- 
rated by a moment of calm from the second period, 
which is of about the same duration as the first. 
The third period, less sharply divided from the 
second than is the second from the first, lasts from 
five to fifteen minutes, the three stages occupying 
something like half an hour. The fourth period, 
that of delirium, is rather more indefinite, both in 
its character and duration, than the other three, since 
it is hard to fix a limit to the time when normal 
intellection appears and terminates the scene. 



^ 



Plate III. 




Fig. I. 




Fig. II. 
The Convulsive Attack — Third period or period of passionate attitudes. 

Fig. 1. — The Phase of Sadness. 

Fig. 2.— The Phase of Exhilaration. 



CONVULSIVE ATTACKS. 139 

There is no regularity in the recurrence of the 
attacks of grand hysteria — in some cases attacks 
are separated by long intervals, months or years ; 
again, they may be of daily occurrence. As has 
been noted elsewhere, the exciting causes are 
many and various, and after the condition has once 
been established, causes the most trivial may pro- 
voke an attack. It would seem, from a careful 
review of the literature on the subject, that attacks 
of grand hysteria are rather more liable to appear 
near the menstrual period in this country than in 
France. It is difficult to say just what relationship 
may exist between painful menstruation and attacks 
of hysteria, but there can be no doubt of their 
association. Attacks of grand hysteria may succeed 
one another rapidly, leaving only some hours' interval 
for repose and nourishment. This succession of 
attacks may continue for weeks or even a month, 
and yet the general health is very slightly impaired 
provided nourishment be kept up. These cases 
resemble in many respects the status epilepticus, but 
differ, as will be seen, in many important particulars. 
There are cases of hysterical attacks that are not 
unlike petit mal ; several such have come under my 
notice in which there was apparently a momentary 
loss of consciousness. Close investigation has in 
most instances satisfied me that there is not absolute 
loss of consciousness, and the association with other 
stigmata has decided the question. Still there are 
cases in which it is extremely difficult to draw the 
differential line between petit mal and hysteria. 



140 HYSTERIA : ITS NATURE AND TREATMENT. 

Thus it is seen that all the types of epilepsy are 
represented in the convulsive attack of hysteria* 
grand mal, petit mal, status epilepticus, and irregular 
forms. We should bear in mind, however, that this 
is not an instance of the mimicry of hysteria, but 
only of the fact that both hysteria and epilepsy are 
but symptoms of some disturbance of the motor 
cortex, the cause underlying this disturbance being 
entirely and radically different in the two cases. The 
fact must not be overlooked, that in rare instances 
hysteria and epilepsy may present themselves in 
the same patient, and cases have been reported in 
which it would seem that the attack itself combined 
some of the symptoms of both affections. 

It will be obvious from the description here'- given 
of the grand attack, that it is the highest manifesta- 
tion of hysteria — consciousness abolished, sensation 
lost, motion violently disturbed and incoordinate. 
Preceding the attack the somatic and mental stig- 
mata of the disease are intensified, and as sequelae 
we see contractures and paralyses. The great 
variation in the symptoms, both as regards form 
and intensity, is to be noted. Going back to the 
theory as to the nature of hysteria, advanced in a 
previous chapter, namely, that the disease is depend- 
ent upon protoplasmic alteration in the cells com- 
posing certain of the higher cerebral centers, it will 
be seen that of necessity we should expect the 
symptoms to correspond to the extent and degree 
of these chancres. 



CHAPTER VI. 
THE MENTAL CONDITION IN HYSTERIA. 

While it is not easy to present a satisfactory 
picture of the somatic stigmata of hysteria, it is far 
more difficult to describe the mental symptoms. As 
Charcot says, " Hysteria is a psychic disorder par 
excellence!' According to the views advanced in 
another chapter, hysteria is a disease of the higher 
centers of the brain, and consequently we would 
expect to find the mental symptoms prominent. 
Again, from the nature of the case, it is ah but 
impossible to classify these symptoms, or to de- 
scribe a typical case. The whole essence of hys- 
teria centers in the disordered function of certain 
areas of the cerebral cortex, and a description of 
the mental state seen in hysteria would include a 
psychological analysis of tl;e hysterical mind. In 
this analysis it would be absolutely necessary to 
include the hereditary influences, the environment, 
and all the moral, intellectual, and emotional forces 
bearing upon the individual case. Again, to make 
the picture complete, we would have to go over 
much of the ground already covered, and show 
how the somatic stigmata have resulted from the 
disordered higher centers. It has seemed to me 

that the modern French school has erred somewhat 

141 



142 HYSTERIA : ITS NATURE AND TREATMENT. 

in the treatment of this part of the subject. On the 
one hand they have drawn a rather too pronounced 
picture of certain of the more grave symptoms, and 
on the other they have hardly presented an ade- 
quate description of the slighter, interparoxysmal 
symptoms. In this country the former set of symp- 
toms, characterized by hallucinations, loss of memory, 
double personality, and the like, are comparatively 
rare, while we have to deal every day with the 
psychic manifestations of the hysterical tempera- 
ment. Again, with us it would seem to be far 
more common than it is in Europe, to have a blend- 
ing of hysteria and hypochondria. Many cases of 
so-called neurasthenia are really made up of the 
symptoms of hysteria plus symptoms of hypochon- 
dria. 

The mental condition accompanying the hysterical 
temperament in the interparoxysmal state is so well 
known that it hardly merits any special description. 
There is a certain condition of mind that we have 
come to recognize, and have termed it, appropriately 
or not, "hysterical." This mental state is seen as 
an interparoxysmal symptom. Indeed, it cannot 
properly be called a symptom at all, but is merely, 
to use an artist's phrase, the "atmosphere" of the 
picture. In a paper* published several years ago, 
some of the characteristics of the mental condition 
in hysteria were described. It would seem, and this 
is a point that has not been clearly brought out, that 

* Preston, New York Medical Journal, 1 889. 



THE MENTAL CONDITION IN HYSTERIA. 143 

we may have well-marked mental symptoms of hys- 
teria unaccompanied by any of the various well- 
known somatic stigmata, such as convulsions, par- 
alysis, anesthesia, hyperesthesia, and the like. In 
this country especially, hysteria seems to manifest 
itself by mental symptoms. The intellectual state 
is characterized by instability, motility, capricious- 
ness. As Sydenham * so well says, " what is most 
consistent is their inconsistency." The subjects of 
mild forms of mental hysteria are inclined to be 
irritable ; they change rapidly from one state to 
another ; are, to quote Richer, -j- " like children, in 
whom one may provoke laughter while their cheeks 
are still wet with tears." There is often present a 
decided exaltation of the intellectual faculties. Such 
a person may at times be a brilliant conversationalist 
— versatile, witty, and gracious for a time — some 
unimportant event, some meaningless remark, may 
bring on a torrent of tears or provoke a fit of un- 
controllable anger. The mental reflexes are, so to 
speak, all heightened, and stimuli brought in from 
without, or originating in the imagination, overrun 
their natural boundaries, and excite more centers 
than they should, and to too high a degree. Some 
trivial and unimportant cause will often provoke a 
powerful exhibition of emotion, nor can we predict 
which particular emotion will be called forth. Given 
a certain stimulus, .as, for example, the relation of a 



* Op. at 

I " La Grande Hysteric 



144 HYSTERIA: ITS NATURE AND TREATMENT. 

piece of bad news ; it is impossible to foresee whether 
the hysterical patient will weep or laugh, will be ex- 
alted or depressed. 

Most of the events in the every-day life of these 
individuals take upon themselves a sentimental cast, 
and questions of the most matter-of-fact nature are 
invested with a halo of romance. The whole intel- 
lectual life, like a kaleidoscope, is changed by the 
slightest movement, and the changes rapidly succeed 
one another. Such individuals are, as a rule, in- 
capable of long-continued application, and as a con- 
sequence of this are rarely able to complete any 
serious undertaking. The spirit of contradiction is 
very strong with them, and they seem to take great 
delight in denying to-day what they affirmed yester- 
day. They will oppose, contradict, and set them- 
selves directly against the wishes of those who are 
dearest to them, and seem to experience a certain 
gloomy pleasure in thus torturing themselves by 
distressing their friends. One ever-present trait, 
serving as a mainspring for many of their actions, 
is an overweening egotism and a morbid desire for 
notoriety. 

Hypochondria, with often a tinge of melan- 
choly, is frequently present, especially in children. 
Such characteristics as vanity, love of notoriety, 
inconsistency, simulation, and the like, has led some 
writer to make the very ungallant remark, that 
in the slighter mental phases of hysteria are to be 
seen in an exaggerated form merely certain feminine 
traits. Most of these symptoms, in a mild degree, 



^rw 



THE MENTAL CONDITION IN HYSTERIA. 145 

might be considered physiological rather than patho- 
logical, and characteristic of puberty. Yet, when 
they become pronounced, they point clearly to a dis- 
tinct, though slight, disturbance of the equilibrium 
of the higher centers. 

The duration of this stage is very uncertain ; 
sometimes it appears at the menstrual period only, 
and lasts but a few days ; aorain, it may continue 
for weeks or months. 

These slight though somewhat characteristic men- 
tal manifestations of hysteria are usually seen at or 
near puberty, between the years of twelve and six- 
teen, though it is no uncommon thing to see the 
same, or at least very similar, symptoms occurring 
late in life, and in both sexes. As has been said, it 
is hardly appropriate to designate the symptoms 
described above as hysteria, yet they have for so 
long a time been so regarded, at least popularly, 
that it is impossible to place them in any other cate- 
gory. Passing on to more marked phases of hys- 
teria, in which the interparoxysmal stigmata are 
pronounced, certain distinct mental symptoms are 
seen which are common to a large class. The 
distinct, clearly-defined mental phenomena — what 
might be called the mental stigmata — appear just 
before, during, or immediately after an attack. In 
other words, they are closely related to, and in a 
sense may be said to form part of, the attack. In 
the first case the mental symptoms are to be re- 
garded as prodromes of the attack. The whole 
mental state of the patient undergoes a marked 
13 



146 HYSTERIA: ITS NATURE AND TREATMENT. 

change ; she becomes irritable, morose, easily ex- 
cited. The emotional nature of the patient becomes 
prominent, and the slightest stimulus provokes an 
outburst. So characteristic are these mental symp- 
toms, that they foretell, with certainty almost, the 
onset of a paroxysm. 

Occasionally, as Charcot has pointed out, the 
mental disturbance may take the place of the 
convulsive seizure, corresponding to the psychic 
equivalent in epilepsy. The sleep, for some 
time preceding the attack, is apt to be restless, 
and nightmares and nocturnal hallucinations are 
present. These dreams, or, as they may sometimes 
be called, hallucinations, frequently make such a 
profound impression that the subject of them may 
be under their dominion for days afterward. Many 
of the " possessions " of the middle ages were char- 
acterized by nocturnal phenomena, producing such 
profound impressions on the mental condition that 
innocent persons were accused of frightful crimes, 
and many of them were put to death on the evi- 
dence given by hysterical girls, as in the case of 
Urbain Grandier (chap. 1). 

Suggestion, coming either from without or within, 
plays a prominent part in mental hysteria. As has 
been noted before, the various phenomena of hys- 
teria present a most striking analogy to the phases 
of hypnotism. Everywhere is to be seen the power- 
ful influence of suggestion, and this is no less true 
of the mental than of the somatic stigmata. There 
is some defect in the co-ordination and regulation of 



^* 



THE MENTAL CONDITION IN HYSTERIA. 147 

the psychic processes. What we loosely call the 
will-power is at fault, is in abeyance, and the emo- 
tions are at the mercy of any passing suggestion. 
Just as in the hypnotic state, wherein any suggestion 
from the hypnotizer is accepted as real and acted 
upon by the hypnotized, so in hysteria the emotions 
may be aroused by some suggestive external cir- 
cumstance, or may even be excited by the uncon- 
trolled and active imagination of the subject. The 
mental features during the attack have been de- 
scribed under the head of the stage of emotional 
attitudes. Following the attack is the stage of 
delirium, of uncertain duration and variable inten- 
sity. In some cases, this stage of delirium dom- 
inates the attack to such an extent that it obscures 
the other symptoms, and constitutes the so-called 
hysterical mania which will be again referred to. 
Disturbance, weakening or entire loss of volition, 
is perhaps the most characteristic feature of the 
mental state of hysteria and is described under the 
name abulia. As it has been aptly put, the hysterical 
patient says, "I cannot;" it looks like "I will not," 
but it really is "I cannot will." 

This weakening of the will-power may attain such 
a high degree that the subject becomes almost an 
automaton, depending for every action upon some 
suggestion. There is a general disinclination to 
exertion, unless the suggestive stimulus be con- 
stantly applied. _ Often there is a decided tinge of 
melancholy present. No phrase is oftener upon the 
lips of the hysterical subject than " I cannot." Even 



148 HYSTERIA: ITS NATURE AND TREATMENT. 

when there is no paralysis present, the hysteric pro- 
fesses to be utterly unable to make any physical 
exertion. She will say that it is entirely impossible 
for her to get out of bed, or to walk across the 
room. She will readily acknowledge the import- 
ance of exertion, and will admit that it is necessary 
to do a certain thing, but declares that it is utterly 
impossible. After a time it becomes difficult, and 
finally impossible, for the hysterical patient to fix the 
attention, and the intellectual faculties lie helpless. 

One of my patients, a more than ordinarily intelli- 
gent woman, spends her time bemoaning the fact 
that she cannot read or sew. Her eyesight is per- 
fect, yet for years she has not been able to occupy 
herself, because she says it is impossible for her to 
keep her eyes fixed on a book or on her needle- 
work. Repeated assurances from a skilled oculist 
have been given her that she could use her eyes, but 
to no avail. If the apathy into which the hysterical 
patient often sinks as a result of loss of control over 
will be broken by a sufficiently strong stimulus, then 
the emotions thus rudely awakened sweep along 
with uncontrollable force. Moreover, this stimulus 
need not be actually intense, but the weakened will- 
power allows some very trivial and unimportant 
event to become invested with imaginary signifi- 
cance. Such persons will say constantly, "I know I 
should not be disturbed by such a thing, but I am 
utterly unable to control myself/' Janet* speaks of 

* " Etat Mental des Hysteriques." 



THE MENTAL CONDITION IN HYSTERIA. 149 

the " abulia" of sleep. It would seem that some 
hysterical individuals cannot sufficiently "let go 
themselves " to go to sleep. 

As was noted in a previous chapter, the theory of 
the disturbance of the centers presiding over voli- 
tion would seem to furnish the best working theory 
by which to explain the various phenomena of hys- 
teria. With volition abolished, man becomes a mere 
machine ; every action is a reflex. With volition 
weakened, with the center performing its function 
imperfectly, there is established a condition of inco- 
ordination. Centripetal impulses convey informa- 
tion which may be more or less perfectly inter- 
preted, but with volition impaired the responses to 
these impulses are either too feeble or too strong, 
never showing the normal relation. In like manner 
intrinsic stimuli are immeasurably distorted. After 
a process of correct reasoning the hysterical subject 
may come to the conclusion that a certain line of 
action is to be pursued, but this becomes utterly 
impossible because of the impaired volition. When 
this phase of mental hysteria is long continued it 
sometimes happens that there is a very marked 
weakening of the intellectual faculties generally. 

Janet,* in his exhaustive treatise on the mental 
condition in hysteria, dwells at some length upon 
the loss of memory. This is present in varying 
degrees, and may relate to remote or recent events. 
Of course the inability to fix the attention closely 

* Op. cit. 



150 HYSTERIA: ITS NATURE AND TREATMENT. 

would explain the loss of memory for events that 
have transpired during the hysterical period, but it 
would seem that the recollection of early events is 
often very imperfect. Some authors have claimed 
that the misstatements and inaccuracies so common 
in hysterical subjects can be explained by loss or 
impairment of memory. While this may be true in 
some instances, it certainly will not explain all cases. 

After an attack, the recollection of what has taken 
place is usually vague and uncertain, though there 
is rarely the complete blank, such as is seen after 
an epileptic seizure. The patient will generally 
remember certain events in the early part of the 
attack, and in some cases will be able to recall a 
good deal of what has happened through the whole 
period. 

In very pronounced cases of hysteria there may 
be seen a sort of fixed idea, or, as Janet calls it, a 
"subconscious fixed idea." As a rule, these fixed 
ideas have a distinct melancholic tinge, or hypo- 
chondriacal character, and it is at times difficult to 
decide whether they really belong to hysteria or to 
pure mental disease. These fixed ideas show them- 
selves particularly during an attack, and sometimes 
apparently have their origin in the dreams and 
nightmares already alluded to. 

During the attack, or sometimes in the interpar- 
oxysmal period, there may be, in hysterical women, 
an evident desire to attract the opposite sex, but it 
is doubtful whether there is actually much sexual 
excitement. Most authors agree that there is a 



THE MENTAL CONDITION IN HYSTERIA. 151 

diminution, rather than an increase, of sexual de- 
sire. 

The many curious instances of double personality, 
or double life, that are reported show certain distinct 
hysterical stigmata, and a large proportion of them 
belong in the category of mental hysteria. These 
cases will be alluded to again. 

In addition to the mental changes mentioned 
above, there are other mental disturbances that pre- 
sent more marked symptoms. These cases belong 
in the debatable ground, and it is often impossible 
to say to what extent they are hysterical. The 
most characteristic form that these graver manifes- 
tations of mental hysteria assume is what has been 
called hysterical mania. As a rule, the condition is 
a continuation of the stag-e of delirium which con- 
eludes the attack. The maniacal attack may, how- 
ever, appear with few or none of the symptoms of 
the convulsive seizure, and in this case is to be 
regarded as the psychic equivalent. Pitres,* in de- 
scribing hysterical mania, says : " Hysterical mania 
does not differ from simple mania or epileptic mania 
except in its etiology. It occurs in old hysterics or 
those predisposed to hysteria, and generally follows 
some profound emotion, particularly fear. It is seen 
much oftener in women than in men, and in some 
cases it has a tendency to recur regularly at the 
monthly epochs." Tomlinson,-j- in reporting six cases 
of hysterical mania, says : "I would define hysterical 

* Op. cit. -\Jonr. of Nerv. and Ment. Dis., vol. xvi, 1891. 



152 HYSTERIA: ITS NATURE AND TREATMENT. 

mania as a form of mental disturbance, character- 
ized by mental exaltation, sometimes varied by 
depression, varying degrees of violence, irrational 
conversation, with or without hallucinations, and 
without delusions ; accompanied by exaggerated 
conduct, the actions of the patient being purposive 
and suggested, and governed by the surroundings." 
Sometimes the mental depression is so marked that 
the case closely resembles one of acute melancholia. 
The question, of course, to be decided in all this 
class of cases is, whether we are dealing with hys- 
teria pure and simple, or whether there is a pure 
insanity, painted, as Mitchell so well puts it, upon 
a hysterical background. It is no uncommon thing 
to find the somatic stigmata of hysteria well marked 
in the insane, and in like manner hysterical mental 
symptoms are often intricately blended with symp- 
toms of pure insanity. There can be no doubt, 
however, that there are cases, perhaps not very 
numerous, but distinct in their symptomatology, 
which resemble closely some of the forms of insanity 
proper, especially mania and melancholia, but which, 
from their origin, course, and termination, must be 
regarded as distinctly hysterical. From what has 
been said in regard to the milder mental changes, it 
will be seen that an intensification of these symp- 
toms will produce a picture similar in many respects 
to certain forms of insanity. While official recog- 
nition, so to speak, has hardly been accorded hys- 
terical insanity, still in nearly every asylum there 
are cases that are so classified. The duration of this 



THE MENTAL CONDITION IN HYSTERIA. 153 

mental disturbance varies from a few minutes — as 
the maniacal delirium immediately succeeding the 
crave attack — to several months, or even longer. 
x\s has been noted, there is often a tendency for the 
attacks to recur, especially near the menstrual period, 
or as the result of some profound emotion. 

The following case, which was under my care for 
several years, will illustrate some of the features of 
hysterical insanity. Miss X, aged eighteen, of 
healthy parentage, with an exceptionally good per- 
sonal history, had a somewhat complicated love 
affair, which seemed to be the starting-point of the 
hysterical symptoms. Her mother described her as 
a very tractable and obedient child, and very affec- 
tionate in her disposition. It would seem that she 
had been somewhat overindulged as a child. The 
hysterical symptoms manifested themselves by a 
change in disposition ; she became wilful, disobe- 
dient, irritable, and unmanageable. She would say 
outrageous things, and seemed to delight in shock- 
ing the sensibilities of those about her. There was 
never any evidence of delusions or hallucinations. 
She was sent to a hospital, where she was regarded 
as hysterical and " devilish." She ran away from 
the institution, and after remaining at home for a 
time became very troublesome on account of her 
many freaks. 

Upon examination there were no somatic stig- 
mata, except marked ovarian tenderness, which 
could not be accounted for, as there was no disease 
of these organs. She was very obstinate, utterly 
14 



154 HYSTERIA: ITS NATURE AND TREATMENT. 

refusing to do what was required of her. At 
times she was very agreeable and entertaining ; 
again, sulky and fretful. Her emotions were very 
easily aroused, and she professed to take great 
interest in the Catholic religion, thou eh she was a 

<_> ' o 

member of another church. While in the hospital 
she pretended to take poison, and she confessed to 
me that she used to take great delight in terrifying 
her mother, by showing her a bottle of laudanum 
and telling her that she had swallowed the whole of 
it, when in reality she had only taken a few drops, in 
order, as she said, to cause her breath to smell of 
the drug and thus deepen the impression that she 
had seriously attempted suicide. On one occasion 
she turned on the gas in her room and was nearly 
suffocated, but she confessed that she had no inten- 
tion of committing suicide, her purpose being to put 
herself slightly under the influence of the gas, and 
then turn it off and enjoy the sensation thus pro- 
duced. She, however, inhaled more than she had 
intended, and as she went to turn it off she fell, and 
but for the fact that she was discovered she would 
undoubtedly have been suffocated. This would have 
been regarded as a suicide of an hysteric, when, 
from her own confession, nothine was further from 
her thoughts. 

In her case there seemed to be some sexual ex- 
citement, and she probably masturbated. By strict 
isolation, firm discipline, and suggestive treatment 
she was entirely cured in a few weeks. After her 
recovery she told me that all the time she felt that 



THE MENTAL CONDITION IN HYSTERIA. 155 

she was doing wrong, and was greatly distressing 
her mother, of whom she was very fond, but that 
she was utterly unable to resist the temptation to 
create a sensation. Some months after this she was 
married, and about the time of her confinement she 
fell into somewhat the same condition as that which 
has been described, only more pronounced. She 
continued to grow worse, and a well-known alienist 
pronounced her case one of chronic mania. She 
remained in this condition for some months before I 
saw her. When she again came under my care she 
was in a bad condition physically, anemic, somewhat 
emaciated, with furred tongue and obstinate consti- 
pation. She was obstinately mute, refused food, and 
had to be fed with a tube for several weeks. 

In two or three weeks she began to eat, but 
remained mute for more than two months. She 
understood all that was said, and would occasionally 
laugh at some remark made in her presence. She 
was sent to an asylum in the country, and in a few 
months recovered perfectly. She never, in the 
whole course of her disease, had any delusions or 
hallucinations, and after her recovery could describe 
very clearly the events of the months of illness. 
Several times during the course of her disease she 
became very much excited, and if she became angry 
would strike the nurse, but apparently never tried 
to do any great injury. At one asylum she several 
times tore up the bed-clothes and broke the furni- 
ture, because she was not permitted to have her 
own way. 



156 HYSTERIA: ITS NATURE AND TREATMENT. 

This case is related at some length because it 
illustrates the difficulty often experienced in making 
a clear diagnosis in cases of mental hysteria. There 
was no evidence, in this case, to show that there was 
anything but hysteria, and yet many forms of pure 
insanity were suggested. 

It frequently happens that degeneracy is con- 
founded with hysteria, and, as a matter of fact, it is 
often not an easy thing to draw the line between 
the two conditions, for the reason that after pro- 
longed mental hysteria there may be seen some 
degeneration. There is a set of mental phenomena 
which, when slight, are very difficult of classification ; 
such as the fear of soiling the hands, doubt as to 
whether some accustomed duty has been properly 
performed, etc. A patient of mine had to give up 
his place as reporter on a newspaper, because he 
was in constant dread of making mistakes in his 
copy, and resigned a Government position of trust 
because he feared he would commit some grave 
error in his accounts. Another patient tried for 
more than a year to force himself to get on a 
railroad train. His business called him often to 
another city, and it was nearly two years before 
he was able to travel. He would often purchase 
his ticket and pass through the gate, and then turn 
back. He had no fear of accident, but, as he said, 
he could not get on the train. These symptoms 
are very often associated with hysteria, but in like 
manner they are perhaps more frequently signs of 



THE MENTAL CONDITION IN HYSTERIA. 157 

degeneracy. In this connection Kirchhoff* remarks : 
" The basis of hysterical insanity is a degeneration, 
and can be regarded as a mental invalidism which 
imparts to the symptoms of the psychosis their 
direction." While, as has been said, signs of 
degeneracy appear after severe and long-continued 
mental hysteria, this is the exception and not the 
rule, and one is often surprised to find so few- 
mental changes after protracted hysteria of an 
aggravated type. 

As to the prognosis of hysterical mental disease, 
Kirchhoff f takes rather a grave view ; he says : 
"The course of all the mental disorders which are 
associated with hysteria may be extremely variable. 
If the mental disturbance occurs in paroxysms, the 
chances of recovery of the individual are favorable, 
although relapses and new attacks are probable. 
On the whole, the prognosis of the mental disorders 
of hysteria is unfavorable, despite the probability 
of the subsidence of the individual attack." This 
prognosis is certainly unnecessarily grave ; hys- 
terical mental disorders tend to recover in most 
instances if they are uncomplicated. It must be 
borne in mind, however, that a very considerable 
number of the cases which are regarded as hysteri- 
cal insanity are complicated with neurasthenia or 
hypochondria, and a large proportion have a bad 
hereditary history. 



* " Handbook of Insanity." 
f Op. at. 



158 HYSTERIA: ITS NATURE AND TREATMENT 

The question as to whether hysterics ever commit 
suicide must be answered in the affirmative. There 
is certainly no disposition on the part of hysterical 
individuals to take their own lives ; nothing is more 
frequently on their lips than the expressed desire to 
kill themselves, and yet suicide, as a result of hys- 
teria, is exceedingly rare. Legrand du Saulle* thinks 
the tendency to suicide is common enough, but it is 
rarely carried out. He calls attention to the fact 
that in true insanity there is always a definite motive 
for the suicide — persecution, fear of ruin, etc. — while 
the attempted suicide of hysterics seems to lack any 
distinct motive. The hysteric generally announces 
publicly her intentions, and the apparent attempts 
are made with ostentation. 

Gilles de la Tourettef mentions cases of actual 
suicide in hysterical subjects, carried out with as 
much secrecy and forethought as would have been 
used in true insanity. I have seen one case, that of 
a man of middle age, who was both hysterical and 
hypochondriacal, who shot himself through the head. 
He had never talked of suicide, and the preparations 
were carefully made, nor was there any publicity 
attending the act itself. It must be borne in mind 
that the hysteric may carry the love of notoriety too 
far, and succeed in an attempt that was not intended 
to be successful, as in the case related above of 
Miss X. 



* " Les Hysteriques, " Paris, 
| Op. cit. 



THE MENTAL CONDITION IN HYSTERIA. 159 

Lethargy, Narcolepsy. — Closely allied to the 
various mental phenomena observed in hysteria are 
certain curious modifications of consciousness, of 
which, perhaps, the most striking is hysterical leth- 
argy. This condition has been recognized from a 
very early period, Araetius having called attention 
to it. It is also described in the writings of Galen. 
Accounts of the affection, with illustrative cases, are 
to be found in the works of Ambrose Pare, Syden- 
ham, Charles Lepois, and many other of the older 
authors. Of course, among the ancients there was 
a certain mystery attached to these cases of pro- 
longed sleep, and consequently their accounts have 
to be received with some allowance. The strange- 
ness of this symptom naturally excites public notice, 
and the daily papers are constantly writing up some 
" wonderful case " with wonderful inaccuracy. 

Hysterical lethargy usually comes on suddenly. 
The subject may be pursuing some ordinary avoca- 
tion, when suddenly she falls into a profound sleep. 
Doubtless the origin of some of the fairy tales of 
sleeping princesses are founded upon cases of hys- 
terical lethargy. So sudden is the onset in some 
instances that apoplexy is suggested. Again, and 
perhaps more frequently, the attack is preceded by 
certain prodromal symptoms, malaise, nervousness, 
hallucinations, mental changes, and the like. The 
duration of the attacks is extremely variable; in 
many instances there is only a momentary loss of 
consciousness, resembling a fainting fit or an attack 
of petit mal. Again, the sleep may last for days or 



160 HYSTERIA: ITS NATURE AND TREATMENT. 

even for months. The subject appears simply to be 
in a profound sleep ; the face has a natural appear- 
ance, though at times it may be slightly congested. 
The muscles generally show a certain amount of 
rigidity or intermittent contractions. The eyes are 
closed, and, as Charcot has pointed out, there is a 
constant slight quivering of the eyelids. The pupils 
show no marked or constant change, being some- 
times dilated, sometimes contracted. The pulse 
maintains its normal frequency, and respiration is 
regular and quiet. An important diagnostic symp- 
tom is the temperature, which is never raised. 

In a case seen in consultation not long since, 
the diagnosis of hysterical lethargy had been made, 
partly from the appearance of the patient, and 
partly because the woman had formerly had attacks 
of hysterical lethargy. The thermometer showed 
marked rise of temperature, and a diagnosis of 
apoplexy was made and afterward confirmed. Anes- 
thesia is usually present. In two of my cases there 
was total loss of tactile and pain sense. Gilles de 
la Tourette and Cathelineau * have shown that there 
is marked loss of weight and diminution of all the 
elements of the urine in spite of regular and abund- 
ant feeding. The duration of many cases is so great 
that it is necessary to feed them, and this can readily 
be done, since as the reflexes are not entirely 
abolished, food placed on the back of the tongue 
will be swallowed. The duration of the attacks, as 

* " Progres Med.," 1 890. 



THE MENTAL CONDITION IN HYSTERIA. 161 

has been said, is variable. Gairdner* relates the 
history of a case in which the sleep continued with- 
out interruption for more than five months, and 
Pfendlerf reports one lasting over eighteen months. 
Dana,J in an interesting paper on this subject, has 
collected a number of cases of variable duration. 

Cases have been reported by Semelaigne and 
Janet § of apparent hysterical lethargy terminating 
fatally. The attack may terminate by the patient 
simply waking up, or, what is more common, by a 
convulsive seizure. In many instances it is possible 
to arouse the patient by pressing upon the hystero- 
genic zones. In the case of Katie B., pressure 
on the ovarian zone produced slight convulsive at- 
tacks, but did not arouse her completely. The elec- 
tric stimulation was then tried, and it was found that 
a very mild current, either galvanic or faradic, would 
instantly arouse her. One electrode was placed at 
some indifferent point, and the other, the negative, 
was placed upon a hysterogenic zone. She seemed 
to experience great pain, though her skin was entirely 
anesthetic, and the current strength was only a few 
milliamperes. " Parmentier|| has described a form of 
hysterical sleep which he calls narcolepsy. In this 
condition the subjects are possessed with an uncon- 
trollable desire to sleep. They will fall asleep on all 
occasions, like the fat boy in " Pickwick." It is hardly 
necessary to include these cases in another category, 

* Lancet, 1888. t" Thesis >" Paris > ^33- 

X " Trans. Med. Soc, New York," 1884. 

\ " Arch. Gen. de Med.," 1891. II Loc. cit. 



162 HYSTERIA : ITS NATURE AND TREATMENT. 

since they are apparently similar in most respects to 
the cases of short duration mentioned above. 

In all the cases of lethargy that have been studied 
with care and fully reported, are to be seen many of 
the stigmata of hysteria. It is quite probable that in 
many instances the sleep merely takes the place of 
an attack. Nothing is more common in hysteria 
than for one symptom to assume an intensity that 
completely obscures all the others. Yet in hysteri- 
cal lethargy can be seen reflexes of most of the 
features of an attack. There is a certain amount of 
muscular disturbance always present — rigidity or 
convulsive movements — and anesthesia is marked, 
together with great modification of the mental state. 
This latter symptom is so much more marked than 
the other stigmata that this affection belongs properly 
under the head of mental symptoms. 

Catalepsy, Ecstacy, etc. — It is not unusual to 
find, during some period of the major attack of hys- 
teria, a certain peculiar modification of the muscles, 
which is denominated cataleptoid, or the state of cata- 
lepsy. Generally this manifestation is seen in the 
third stage, or that of emotional attitudes. The 
limbs can be placed in any position, and remain thus 
fixed until the muscles become physiologically fa- 
tigued. While at the beginning of the attack there 
may be some slight rigidity of the muscles, this very 
soon gives way to a condition of wax-like flexibility 
(flexibilitas cerea). These symptoms, as has been 
noted, form a part of the attack, and are not to be 
regarded as constituting a distinct condition. Cases 



THE MENTAL CONDITION IN HYSTERIA. 163 

are met with, however, in which the ordinary symp- 
toms of hysteria are so insignificant, or are so ob- 
scured by the peculiar muscular phenomena, that 
they are regarded as constituting a distinct class, and 
are described under the term catalepsy. Catalepsy 
was made much of by the older writers, and even 
comparatively modern authors describe it as a dis- 
tinct affection (Rosenthal). 

The folio wine citation from Boerhaave,* which is 
quoted in many of the older books, shows in what 
a serious light catalepsy was formerly regarded. 
''Catalepsy," says Boerhaave, "is a dream in which 
the patient becomes of a sudden void of feeling, and 
retains that same position and action of all parts of 
his body which it was in when the disease seized him 
first. This doth happen so seldom that there is 
hardly one physician in ten who in fifty years' prac- 
tice shall happen to see it. Galen, in fifty years' prac- 
tice, saw it but once. It seldom changes into other 
diseases, yet it has sometimes been succeeded by the 
falling sickness, convulsions, and foolishness, but 
most times ends in death." 

There can be no doubt of the fact that the isolated 
cases of catalepsy are distinctly hysterical in nature, 
and often, as has been noted, take the place of the 
convulsive seizures. 

There would seem to exist in many hysterical per- 
sons a sort of cataleptoid tendency at times other 
than during the grand attack. The abulia, or loss 

* "Aphorisms," London, 1735. 



1 64 HYSTERIA: ITS NATURE AND TREATMENT. 

of will-power, which is the fundamental condition 
underlying the hysterical state, makes more or less 
of an automaton of the subject. Suggestions are 
easily accepted and readily acted upon, and this fact 
would in large part explain the phenomenon of cata- 
lepsy. This condition is not, however, peculiar to 
hysteria, since it is seen in certain forms of insanity, 
notably the katatonia of Kaulbaum, and some forms 
of simple melancholia. Again, the cataleptoid state 
is one of the distinct phases of hypnotism. Evi- 
dently we have to deal with some disturbance of the 
normal relation which exists between the higher and 
the lower, or motor centers ; the subject is not able 
of his own will to set the motor mechanism in 
operation. 

It is clear that catalepsy should no longer be re- 
garded as a distinct affection, but rather as a symp- 
tom-complex, related to several abnormal mental 
states. 

Another phase of mental hysteria which is de- 
scribed as a distinct affection in the older books is 
ecstacy. Enough has been said in chapter i to 
show that this condition was one of the most char- 
acteristic manifestations of hysteria in early times. 
Very generally, as has been shown, the ecstatic state 
was the outcome of religious superstition, and simi- 
lar conditions are sometimes seen in modern times 
among ignorant and superstitious people. 

Ecstacy constitutes one of the phenomena of the 
third stage of the major attack, and is described under 
that section. It is brought about most probably by 



THE MENTAL CONDITION IN HYSTERIA. 165 

hallucinations of the special senses, which are in 
great part forgotten after the subject recovers. 

Closely related to mental hysteria is that curious 
phenomenon known as somnambulism, or sleep 
walking. While, of course, somnambulism cannot 
be strictly regarded as belonging to hysteria, yet 
some of the symptoms observed in this latter condi- 
tion are clearly hysterical in nature. Again, there 
can be no doubt of the fact that somnambulism oc- 
curs, for the most part, if not wholly, in hysterical 
subjects. Somnambulism is seen in children and 
young adults, rarely in elderly persons. The night- 
mares and night terrors of childhood may be re- 
garded as modifications of the condition which, in 
its fully developed state, is spoken of as somnambu- 
lism. One of my patients, a lad of ten, will awake with 
a scream, jump out of bed, and run into another 
room where his parents are — all the while entirely 
unconscious, or at least profoundly asleep. 

Pritchard * says that somnambulism was known to 
Hippocrates and Galen. He describes somnambu- 
lism as " a manifestation of the nervous system, 
characterized by a suspension, more or less complete, 
of external feeling, while the imagination is active." 
Bertrand -j- says: " Somnambulism constitutes really a 
new life, returning at unequal intervals, connected 
together by a new species of memory." 

The attacks are apt to come on about the same 
hour each time, usually after midnight, and can often 

*" Cyclop, of Pract. Med.," 1845. f " Traite du Somnambulisme." 



166 HYSTERIA: ITS NATURE AND TREATMENT. 

be traced to some indiscretion in eating or some un- 
usual excitement. The subject will get up, often 
dressing carefully, and with the eyes either open or 
shut, generally the former, will perform a series of 
acts as naturally as when awake. 

Popular descriptions of somnambulism have dwelt 
rather too strongly on the tendency of somnambu- 
lists to walk on the roofs of houses or other danger- 
ous places. As a rule, they go through some accus- 
tomed routine — a student gets his books, a farmer 
goes to the stable and feeds his horses, etc. General 
sensibility is abolished, or at least is greatly ob- 
tunded, since somnambulists will often hurt them- 
selves without awakening or showing any evidence 
of feeling. 

The special senses — vision certainly and perhaps 
the others — are more or less active. It is probable, 
however, that the special senses are under the domi- 
nation of an autosuggestion or dream. Take, 
as illustrative of this point, the curious case re- 
lated by Muratori,* of a student who was accus- 
tomed to get -up and dress himself, get his books 
together, and spend some hours translating Latin. 
On one occasion some friends came into his room 
and found him thus occupied. They brought a lamp 
and then blew out the candle which was on the stu- 
dent's table. Immediately he ceased his work, 
groped about the room, with difficulty found his way 
to the kitchen, relit his candle, and resumed his occu- 

* Quoted by Pritchard, loc. cit. 



THE MENTAL CONDITION IN HYSTERIA. 167 

pation. In this instance the subject seemed blind to 
all light except his own candle. 

Guinon* cites a case of a young' man whose field 
of yision seemed restricted to the paper upon which 
he was writing. It would seem that in some instances 
there is a decided psychic excitation, persons being 
able to do mental work in a state of somnambulism 
that was impossible for them in their waking 
moments. 

On this point Sir William Hamilton t says: "In 
this remarkable state (somnambulism) the various 
mental faculties are usually in a higher degree of 
power than in the natural. The patient has recol- 
lections of what was wholly forgotten. The imagi- 
nation . . . and the faculty of reasoning are in 
general exalted. It is also true that there is, or at 
least seems to be, an exaltation of muscular sense or 
muscular co-ordination, since some subjects will per- 
form with ease feats that they could by no means 
accomplish so well when in the waking state. The 
mental state of somnambulism differs from that in 
ordinary dreams, in that in the former there is never 
any recollection remaining of what has passed. In 
some mysterious way memory links together the 
somnambulistic periods, the subject when awake 
having absolutely no recollection of what has oc- 
curred during the sleep-walking period, though re- 
membering in one attack what has passed in a former 
one." 

* Progres Med. ,1891. j " Metaphysics. 



1 68 HYSTERIA: ITS NATURE AND TREATMENT. 

Many interesting cases illustrating this point are 
to be found in the literature on the subject. Guinon * 
relates the case of one of his patients who in one 
attack wrote a dozen pages of manuscript, and in 
another attack, three days later, began, without 
hesitation and without referring- to the rest of the 
manuscript, with page 13, also writing the last word 
of page 12. In ordinary dreams there is a slightly 
similar revival of memory. As a rule, the somnam- 
bulist does not vary his performance, but repeats 
the same actions in the same sequence in each 
attack. Space will not permit the relation of any 
of the amusing stories of somnambulism with which 
literature, both scientific and popular, abounds. 

The following case, which has been for some years 
under my care, presents some curious features : 
Mr. I., a well-known clergyman of a markedly hys- 
terical temperament, began, about fifteen years ago, 
to have somnambulistic attacks. The attack usually 
comes on after midnight, and begins by loud talking. 
He will often pray as if he were in his pulpit. After 
a few minutes he gets out of bed, walks around the 
room, and invariably looks for the chamber vessel. 
If he succeeds in finding it he passes a large quan- 
tity of pale urine, wanders about for a few minutes, 
and goes back to bed. When he cannot find the 
vessel he will urinate in any convenient receptacle. 
His eyes are staring open and his face has a very 
vacant expression. He will converse with persons 

* Loc. cit. 



THE MENTAL CONDITION IN HYSTERIA. 169 

in the room in a reasonably intelligent manner. He 
rarely goes out of his room, though on a few 
occasions he has done so. The next morning there 
is not the slightest recollection of what has passed. 
If no one has seen him, the only way he is aware of 
having had an attack is that the room is sometimes 
disordered in an effort to find some place to urinate. 
On one occasion he dropped a pitcher and cut him- 
self, and was not aware of the injury until the next 
mornine- The attacks seem to bear some relation 
to indiscretions in diet or to overwork. On one 
occasion he took 60 grains of bromid of potash at 
bedtime by mistake, and had an attack shortly after 
midnight — which would have some weight in ex- 
cluding the possible epileptic nature of the attacks. 
He is not in any manner unconscious during the 
attack, but can recognize persons he knows, and 
will often ask them to get something for him ; but 
it is very difficult to arouse him, or, rather, to restore 
him to his normal mental state. This peculiar con- 
dition lasts usually about half an hour, and the 
attacks come on at irregular intervals, sometimes two 
in a week, or, again, months will elapse between them. 
A condition in many respects similar to somnam- 
bulism, except that it takes place during the day and 
is more prolonged, has been termed by Charcot 
vigilambulism, in contradistinction to noctambulism, 
as he designated the condition we have called som- 
nambulism. In these cases of vigilambulism there is 
a veritable double life, the threads of each being 
taken up where they were broken off. 
15 



170 HYSTERIA: ITS NATURE AND TREATMENT. 

Vigilambulism may last months or even years, the 
subject returning to the normal mental state with no 
recollection of the period of abnormal life. Many 
illustrative instances of this double life could be 
mentioned from both medical and lay sources. The 
most carefully studied and most accurately reported 
case is the classic history of Felida X., so graphically 
described by Azam.* This patient, an hysterical girl, 
would pass into what Azam calls the "second state," 
in which, while her mental faculties were apparently 
perfectly preserved, still her whole character was 
entirely changed. The duration of the abnormal 
state increased from hours to days, weeks, and 
months, until she passed most of her life in this 
" second state." She had not the slightest recollec- 
tion while in one state of what had happened while 
in the other, but her memory was perfect in each 
separate condition, and she would apparently take 
up one life just at the point she had left it perhaps 
months before. The medico-legal aspect of these 
cases is important, since without doubt acts may be 
performed by such persons for which they could 
hardly be held responsible, and, moreover, this con- 
dition may subject persons to the criminal acts of 
others. In the case of Felida X., the girl was 
seduced while in the " second state." 

It is not true, of course, that every sleep-walker is 
markedly hysterical, but there can be no doubt of 
the fact that the great majority of them are. Again 

* " Hypnotisme et Double Conscience." 



THE MENTAL CONDITION IN HYSTERIA. 171 

in some instances where we would hesitate to pro- 
nounce the subject distinctly hysterical there is a 
marked neurotic history. In a certain proportion 
of cases the somnambulistic attack is really a part 
of, or rather a modification of, the major hysterical 
seizure. In fact, the somnambulistic attack may be 
ushered in by a typical hysterical convulsion. In 
studying the phenomena of natural somnambulism, 
one cannot fail to be struck with the close analogy 
which exists between it and the provoked somnam- 
bulism of hypnotism. Charcot long ago pointed out 
the relationship which exists between hysteria and 
hypnotism, — a fact that has been abundantly borne 
out by subsequent observations, — and natural som- 
nambulism would almost seem to be the connecting 
link between the two conditions. 



CHAPTER VII. 

VISCERAL AND VASOMOTOR DISTURB- 
ANCES. 

Digestive disorders of various kinds are fre- 
quently met with in hysteria. The older writers 
laid great stress on this symptom, and Cullen made 
it the basis of a theory of the etiology of hysteria. 
Hysterical subjects nearly always have symptoms 
referable to the stomach. Generally these symptoms 
are vague, corresponding in a manner to the gastric 
paresthesia of neurasthenia. Sensations of fullness 
and distention, of emptiness, of "sinking," of move- 
ment, of indistinct pain, and the like, are complained 
of. As a rule, these subjective sensations are not 
attended by any distinct disturbances of the func- 
tions of the stomach. They constitute, except the 
well-defined cases of neurasthenia, the so-called 
" nervous dyspepsia," another example of a euphe- 
mistic synonym for hysteria. 

But apart from these vague general subjective 

symptoms referred to the gastro-intestinal tract, 

there are certain distinct and well-marked objective 

symptoms. One of these conditions — referred to 

in another chapter — is contracture of the esophagus. 

Sometimes the spasm is clonic in nature, involving 

only, or chiefly, the pharyngeal muscles, but more 

frequently its main seat is in the esophagus. The 

172 



VISCERAL AND VASOMOTOR DISTURBANCES. 173 

contracture takes place at different parts of the tube 
in different subjects, and Gilles de la Tourette * has 
sueeested that in some cases there exists a hystero- 
genie zone in the esophageal mucous membrane. In 
some subjects liquid, in others only solid, food in- 
duces the contracture. As a result of the contrac- 
ture, whether it be in the pharynx or esophagus, the 
food is rejected before it reaches the stomach, occa- 
sionally lodging for a few moments, but it is generally 
returned almost immediately after the attempt to 
swallow. A young negro girl who was under my 
care for some time was unable to swallow any solid 
food, or at least only minute particles. As soon as 
the food passed the pharynx, it seemed to be arrested 
and was at once regurgitated. She lived for months 
on liquid food, with bread broken into minute 
crumbs mixed with her milk or soup. A careful ex- 
amination with the sound showed no organic stric- 
ture, and after lasting for nearly a year the condition 
disappeared. The duration of spasm or contracture 
of the esophagus is uncertain, lasting weeks, months, 
or even years. Often it vanishes suddenly after 
some strong emotion or as the result of suggestive 
treatment. Cases of death from inanition, — due to 
hysterical contracture of the esophagus, — have been 
reported (Briquet) .f Contracture may affect the 
stomach and vomiting result, the food being re- 
jected almost immediately after reaching the stom- 
ach. There is no nausea, and no great amount of 

* Op. cit. | Op. cit. 



174 HYSTERIA: ITS NATURE AND TREATMENT. 

pain or discomfort attending the vomiting. Appar- 
ently as soon as the food touches the mucous mem- 
brane of the stomach a single- contraction takes 
place, the contents of the stomach is expelled, and 
the organ resumes its natural condition. When food 
is introduced by means of a tube, as soon as the 
latter is withdrawn, a simple painless contraction 
takes place and the food is rejected without having 
been acted upon by the gastric juice. 

Hysterical vomiting resembles, in many respects 
the vomiting observed in cerebral disease, but it 
must be borne in mind that in the former case there 
are always present some of the many stigmata of 
the disease, though, as will be noted, these stigmata 
are often ill defined. In vomiting of cerebral origin 
it is practically always possible to make out some 
diagnostic symptoms of intracranial pressure, or 
some grave blood changes. Gilles de la Tourette 
and Cathelineau * have brought out the interesting 
fact that in hysterical vomiting it rarely happens that 
all the food taken by the mouth or introduced by 
the stomach-tube is rejected, thus accounting for the 
fact that in some instances hysterical vomiting is not 
attended with as much emaciation as would be ex- 
pected. In many cases, however, — in fact in all cases 
when the vomiting continues over any considerable 
period, — emaciation becomes profound, and cases of 
death have been reported with autopsies showing no 
lesions whatever ; as, for example, the case reported 

*" La Nutrition dans L'Hysterie." 



VISCERAL AND VASOMOTOR DISTURBANCES. 175 

by Robinson.* Of course, instances of death from 
hysteria or any of its complications are always 
regarded with suspicion, and justly so, yet the case 
above alluded to, and a few other similar ones, would 
seem to leave no doubt of the fact that fatal results 
have followed long-continued vomiting of purely 
hysterical origin. It has been suggested that some- 
times atonic vomiting and dilatation may be due to 
paralysis of the muscular coats of the stomach, the 
paralysis, of course, being of hysterical origin. 

In addition to the vomiting of food, hematemesis 
is occasionally observed in hysterical subjects. The 
quantity of blood vomited is usually small, though 
cases have been reported of large hemorrhages, 
which were considered of hysterical origin ; as, for 
instance, the case of Bouloumie,f in which as much 
as a liter of blood was vomited. Sometimes the 
blood is mixed with the food, but oftener it is ex- 
pelled as pure blood of a bright red color, or only 
slightly mixed with mucus. The blood may show 
signs, occasionally, of having undergone partial 
digestion, appearing in brownish clots. The hemate- 
mesis may occur at irregular intervals and often 
extends over many months' duration. Undoubtedly 
most of the cases of so-called vicarious menstrua- 
tion are really instances of hysterical hematemesis. 

There is at present under my care a young girl 
with many well-marked stigmata of hysteria, such as 
hysterogenic zones and hemianesthesia, who has at 

* Lancet, 1893. -j- Union med., 1880. 



176 HYSTERIA: ITS NATURE AND TREATMENT. 

times typical attacks of hysterical vomiting. The 
vomitine is at times so severe and loner continued 
that it is necessary to feed her by the rectum. At 
intervals she has hematemesis, this symptom usually 
occurring near the menstrual period. She will men- 
struate for several days, vomiting small quantities of 
bright red blood at the same time, and the hemate- 
mesis will continue for several days after the men- 
strual period has passed. She also has attacks of 
hematemesis in the intervals between her menstrual 
periods ; her stomach has been very carefully ex- 
amined, and no evidence of any digestive disturb- 
ance can be detected. This patient has a brother 
who gives a history of similar attacks of vomiting of 
blood. It is almost certain, as has been said above, 
that the hemorrhages that are observed from various 
mucous surfaces, and which are spoken of as in- 
stances of vicarious menstruation, are in reality vaso- 
motor hysterical manifestations. The association of 
this symptom with the menstrual epoch is in accord 
with the frequently observed exacerbations of hys- 
terical symptoms at this time. While hysterical vom- 
iting of blood is nearly always seen in women, cases 
have been reported in men. 

Gilles de la Tourette has suggested — and the 
suggestion is worthy of careful consideration — the 
possibility of confounding hysterical hematemesis 
with gastric ulcer. He examined a number of cases 
diagnosed as gastric ulcer in the Paris hospitals, 
and found a large percentage of hysterical subjects 
among them. The fact that gastric ulcer is most 



VISCERAL AND VASOMOTOR DISTURBANCES. 177 

frequently seen in young females, and that very 
often there are few local symptoms, emphasizes 
the necessity of excluding hysteria. Again, it not 
infrequently happens that there may be areas 
of hyperesthesia in the region of the stomach 
of patients presenting the symptom of hysterical 
hematemesis, so that the resemblance between the 
two affections may be very close. 

A very common gastric disturbance met with in 
hysteria is hysterical anorexia, or anorexia nervosa. 
In the forms of hysterical vomiting described above, 
there, comes a time when the patient is unwilling to 
take food for fear of disturbing the stomach, and 
when some obstruction, as contracture of the esoph- 
agus, exists, the difficulty in swallowing is so great 
that the subject would rather go without food than 
experience the discomfort of attempting to force it 
through the constricted passage. This is not, how- 
ever, what is meant by hysterical anorexia. In this 
latter condition there exists no reason why food 
should not be swallowed and digested. The patient 
simply says that it is impossible to eat. This symp- 
tom was first described by Lasegue * and Sir William 
Gull,*)- and since their observations many cases have 
been reported. There is no evidence of any distinct 
fixed idea, such as we see in the insane ; or, at all 
events, hysterical subjects rarely assign any cause 
for their refusal to take food. 

Occasionally, perhaps, they may express a desire 



* Arch. Gen. de Med., 1873. \ Brit. Med. Jour., 1873. 

16 



178 HYSTERIA: ITS NATURE AND TREATMENT. 

to reduce their weight, but this is rare. As a rule, 
they begin by refusing certain articles of food, or 
confine themselves to one. Sometimes this is 
accompanied by a desire for things that are unfit 
for food — the well-known conditions of pica and 
malacia of the older writers. Sometimes gradually, 
sometimes suddenly, the patient refuses food almost 
entirely. Of course, there are many cases that 
should not be included in this category, — cases of 
wilful deception, in which the patient publicly refuses 
food and consumes large quantities in secret. In 
cases, however, about which there can be no doubt, 
it is astounding how lon^ the anorexia and the con- 
sequent starvation may go on without producing 
emaciation. Often the subject will seem unusually 
active and vigorous, while seemingly taking a very 
insufficient amount of nourishment. After a time, 
if the condition be pronounced, emaciation begins 
to show itself. The patient becomes anemic, loses 
flesh steadily, the skin becomes dry, and in a num- 
ber of perfectly authentic cases death has resulted. 
The idea, which was long prevalent, that in hysteri- 
cal vomiting and hysterical anorexia nutrition is not 
impaired has been clearly exploded by the careful 
observations of Gilles de la Tourette * and Cathe- 
lineau.f These authors noted the exact amounts of 
food taken by patients affected with one of the con- 
ditions described above, and in the case of vomiting 
noted the amounts of food rejected ; and by weighing 

* Loc. cit. -j- Loc. cit. 



VISCERAL AND VASOMOTOR DISTURBANCES. 179 

the patients daily showed that in hysteria, as in any 
other condition, it is necessary to eat to live. 

The fallacy in the older observations, as these 
authors have pointed out, lay in the fact that while 
the hysterical patient apparently vomited everything 
that was put into the stomach, in reality enough 
food was retained to maintain life. There would 
seem to be no doubt of the fact, however, that the 
hysterical subject can keep up the nutrition of the 
body on rather less food than a normal individual. 
As a rule, there rarely exist any other well-marked 
stigmata during the course of the anorexia, or, as 
Lasegue says, "the other symptoms are suspended." 
The duration of hysterical anorexia is very variable, 
lasting weeks or months. 

One of the most marked cases that has come 
under my observation was that of a young girl 
about nineteen years of age who, for no ascertain- 
able reason, gradually refused to take food. For 
weeks she led a very active life, walking, playing 
tennis, etc., with no apparent ill-effects. She then 
began to lose flesh, until she became a mere skele- 
ton, having emaciated almost to the physiological 
limit. A careful examination revealed no cause for 
the emaciation, and a diagnosis of hysterical anorexia 
was made. A little judicious neglect of the patient, 
with an active out-door life, rapidly brought about a 
cure. In a case seen recently, a girl of nineteen 
had lost more than 40 pounds. She would assign 
no cause for her refusal to eat, saying simply that 
she did not care for food. Her color was good, but 



180 HYSTERIA : ITS NATURE AND TREATMENT. 

she was extremely weak and unable to make any ex- 
ertion. In neither of these cases, which were both 
undoubted instances of hysterical anorexia, were 
there any well-marked somatic stigmata of hysteria. 

Sollier and Parmentier,* after a number of careful 
observations, conclude that in hysterical anorexia 
there is no important modification in the character of 
the gastric juice. 

It is doubtful, as has been said, whether hystero- 
genic zones, or patches of anesthesia, exist, or at any 
rate are prominent factors in the gastro-intestinal 
disturbances described above. We are then forced 
to the conclusion that these peculiar, and fortunately 
rather rare, manifestations of hysteria are central 
and not peripheral, and are to be classed rather with 
the mental than the somatic stigmata. And yet this 
explanation is not altogether satisfactory, since, as 
has been noted, it is not often possible to bring out 
anything approaching a fixed idea dominating the 
digestive system. We can merely refer the gastric 
disorders observed in hysteria to some disturbance 
in that part of the cortex representing the gastro- 
intestinal tract. In the present state of our knowl- 
edge, it is impossible to say to what extent these dis- 
turbances are to be regarded as trophic manifesta- 
tions. 

Intestinal disorders are not infrequent in hysteria ,; 
there may be a watery diarrhea — the so-called ner- 
vous diarrhea — or obstinate constipation may exist. 

* Congres de Lyon. 



VISCERAL AND VASOMOTOR DISTURBANCES. 181 

These conditions have no distinctive features, and are 
only recognizable by the absence of any apparent 
cause, together with the association of other hysteri- 
cal symptoms. It is possible that in some cases the 
constipation, which is often of long duration and 
very hard to overcome, may be a part of the gen- 
eral paralytic phenomena. The cause of the diar- 
rhea is by some observers regarded as an excessive 
peristalsis, by others as due to certain indefinite 
trophic lesions in the intestinal mucous membrane. 
By far the most interesting and characteristic affec- 
tion of the intestine met with in hysteria is the 
enormous distention of the bowel with gas. In many 
hysterical subjects there are sensations of distention 
without any distinct increase in size, but now and 
then cases are seen in which the abdomen becomes 
enormously enlarged. Joly * reports a case in which 
the collection of gas was so great that the patient 
was enabled to float in water. 

There is unquestionably an important mental ele- 
ment relating to the etiology of hysterical tympanites, 
for in many cases there is either the strong desire to 
become pregnant, or the stronger emotion of fear 
lest this condition be present. In a case now under 
observation, the patient, a young girl with a moder- 
ate degree of abdominal distention, believed herself 
to have become pregnant from masturbation. Usu- 
ally, however, the fear is not so groundless as in this 
case. In some cases there is the history of a trau- 

* " Ziems. Encyc." 



182 HYSTERIA: ITS NATURE AND TREATMENT. 

matism, received under emotional circumstances. 
Perhaps the most frequent cause of hysterical tym- 
panites at the present day is the dread of abdominal 
tumor. The distention of the abdomen is usually 
general and regular, occasionally limited to one side, 
or even more sharply defined. In most cases there 
is no pain complained of, though occasionally there 
is the most intense hyperesthesia. Respiration is 
sometimes interfered with by the distended intes- 
tines pushing up the diaphragm and encroaching on 
the thoracic cavity. 

In the cases of simple distention where there is no 
pain, there is often a close resemblance to pregnancy. 
Literature abounds in instances of this nature, and 
most obstetricians can recall amusing cases of false 
pregnancy. The cases in which there is hyperes- 
thesia suggest chronic peritonitis, and those present- 
ing localized swellings, tumor. As a matter of fact, 
such cases have been wrongly diagnosed and even 
operated on (Simpson, Potain). Of course, it is 
always possible to settle the diagnosis by the admin- 
istration of an anesthetic, when the phantom tumor 
or the false pregnancy resolves itself to reappear 
after the effects of the anesthetic are recovered from. 

Various theories have been advanced to account 
for the origin of the gas in hysterical tympanites, 
but as yet there is no very satisfactory explanation. 
It has been suggested that it may be the result of 
the fermentation of food, but this is not borne out 
by the studies of the digestion in these cases. Nor 
is it probable that the gas is simply swallowed. 



VISCERAL AND VASOMOTOR DISTURBANCES. 183 

More fanciful still is the theory that gas is liberated 
from the blood into the intestine. The most prob- 
able solution of the question is that the intestinal 
wall changes greatly in diameter, and the contained 
gases become rarified. In some instances large 
quantities of gas are emitted, either by the mouth or 
the anus, and it may be drawn off by means of a 
rectal tube. This gas, as a rule, is nearly without 
odor. Some of these cases present the troublesome 
and distressing symptom of borborygmus, which is 
often so excessive and uncontrollable that social 
intercourse becomes impossible. 

Cases of hysterical tympanites have been reported 
that resembled very closely intestinal obstruction, 
the symptoms being great distention of the abdo- 
men, pain, and even fecal vomiting. In a case 
reported by Briquet, a solution of litmus injected 
into the bowel was in a very short time vomited. 
This case was watched most closely, and solutions 
of various substances not to be found in the hospital 
wards were injected, all of which were returned by 
the mouth. The course of the gastro-intestinal 
manifestations of hysteria is variable ; now appearing 
as an isolated symptom, lasting a few days or weeks 
and disappearing, or, again, continuing for months. 
There is a marked tendency for these conditions to 
reappear at irregular intervals, and, as a rule, they 
are very resistant to treatment. 

Affections of the Genito-Urinary Apparatus. 
— In the description of the grand attack, and also in 
connection with many of the interparoxysmal symp- 



1 84 HYSTERIA: ITS NATURE AND TREATMENT. 

toms of hysteria, mention has been made of polyuria. 
This symptom has been noted from the earliest 
times, and is to be regarded as one of the classic 
observations in the symptomatology of hysteria. 
The ordinary convulsive seizure very frequently ter- 
minates by a copious discharge of pale urine of low 
specific gravity. In addition to this transient poly- 
uria it would seem that occasionally hysterical sub- 
jects present this symptom for months or even years 
(Gilles de la Tourette).* Axenfeldt and Huchard 
say : " Hysterical polyuria is either transitory or 
permanent. In the first instance, it is a phenomenon 
frequently observed consecutive to some paroxysmal 
seizure, and consists in the emission of a large 
quantity of pale urine. The second variety is much 
more rare, persists a greater or less length of time, and 
is often unassociated with paroxysmal symptoms." 

The pathology of polyuria in general is as yet so 
obscure that we should hesitate to associate perma- 
nent polyuria in a causative way with hysteria. 
Cases have also been reported, especially by the 
older writers (Laycock) of hysterical hematuria. In 
some instances, where this latter symptom was asso- 
ciated with great pain, the kidney has been excised, 
and no stone being found, the diagnosis of hysteria 
was arrived at. The possible sources of error in 
such a diagnosis are apparent. 

A very striking symptom which is occasionally 
observed in hysterical subjects is suppression, partial 

* Op. at. 



VISCERAL AND VASOMOTOR DISTURBANCES. 185 

or complete, of the urine. Laycock, in his essay on 
"Hysteria," published in 1840, declares that the 
mild form of hysterical ischuria is of no uncommon 
occurrence. In discussing the graver form, he re- 
ports a number of cases, some from his own obser- 
vation, but in the main gathered from old sources, 
in which the length of the suppression of the secre- 
tion is utterly incredible. 

Still more incredible are the cases which Laycock 
has collected of what might be called vicarious urina- 
tion. He gravely reports instances, ostensibly worthy 
of credence, of urine passing in considerable quan- 
tities from the umbilicus (case xn, in which, after 
three days of complete suppression of urine, two 
quarts "gushed from the umbilicus"), from the anus 
(case xv), from the mammae and skin (case 
xxvn), from the ears, eyes, and so on. The most 
astounding case of this marvelous collection is taken 
from the American Journal of the Medical Sciences, 
1827, concerning which the reporter, Dr. Arnold, 
says : " Urine next flowed from the left ear, left eye, 
afterward was discharged from the stomach. 
The urine next flowed from the nipple of the right 
breast, afterward from the left, next from the navel, 
and finally nature, wearied in her irregularities, made 
her last effort, which completed the phenomena 
of the case, and established a discharge of urine 
from the nose." These cases are referred to some- 
what at length to show the difficulty in separating 
the spurious from the genuine in the symptomatol- 
ogy of hysteria. As will be seen, there is a grain of 



i86 HYSTERIA: ITS NATURE AND TREATMENT. 

truth present in all this mass of absurd nonsense, 
since unquestionably there is in these cases of ischu- 
ria a certain vicarious urination. 

Charcot,* after going carefully and critically over 
all the reputable cases of hysterical suppression of 
urine, showed conclusively that the condition, while 
rare, really exists. In one case most carefully ob- 
served and hedged about with every precaution to 
prevent fraud, the suppression of urine was almost 
complete for weeks together. At the end of the 
period there would occur a temporary polyuria, last- 
ing a day or two, followed by another long period 
of suppression. In this case, together with several 
others studied by Charcot, the catheter was fre- 
quently used, demonstrating the fact that the urine 
was not passed into the bladder. In these cases 
there was frequent vomiting, and the material ex- 
pelled from the stomach showed urea present in de- 
cided amounts. 

When the amount of urine became very small the 
vomitings would increase, and vice versa. In some 
cases the other emunctories come to the aid of the 
kidneys, and there exists profuse diarrhea, excessive 
salivation, or, as in the case reported by Weir Mit- 
chell, a very copious sweat. In these various ways 
the actual amount of urea removed is considerable. 
In a case of hysteria showing nearly all the recog- 
nized stigmata of the disease, that was under my 
care several years ago, the daily quantity of urine for 

* Op. cit. 



VISCERAL AND VASOMOTOR DISTURBANCES. 187 

months at a time would range from y 2 of an ounce 
to an ounce. An examination of it showed nothing 
abnormal except a relative increase of urea com- 
pounds. In this case there was at times vomiting, 
always very profuse sweating, and the breath had a 
distinctly urinous odor. 

Thus these instances of partial suppression of 
urine — oliguria or ischuria — can generally be ex- 
plained by the fact that the other systems are called 
upon to supplement the work of the kidney, and 
consequently uremic symptoms do not appear. The 
cases of hysterical anuria, or total suppression, con- 
tinuing any length of time, must be received with 
great reserve. The peculiar tolerance of the hys- 
terical subject, illustrated by the cases of long fasting 
previously alluded to, may permit of a certain tempor- 
ary suppression of urine, but unquestionably the sys- 
tem will not be able to endure this state of affairs long 
before symptoms of uremic poisoning begin to show 
themselves. 

The bladder is occasionally involved in hysterical 
subjects, the mucous membrane showing, now, anes- 
thesia or, again, hyperesthesia. This has been alluded 
to in another chapter. It is probable that some 
of the cases of " irritable bladder " are in reality 
instances of hyperesthesia, of a purely hysterical 
nature, of the vesical mucous membrane. Hysteri- 
cal retention and incontinence are met with but have 
no characteristic features. 

Organs of Generation. — It is interesting, in view 
of the derivation of the name hysteria, to see how 



1 88 HYSTERIA: ITS NATURE AND TREATMENT. 

rarely the reproductive organs are the seat of dis- 
tinct hysterical manifestations. The older writers 
dwelt largely upon the participation of these organs, 
both in the etiology and the symptomatology of 
hysteria. When we come, however, to study in a 
scientific manner the stigmata of the disease, we 
find very few constant symptoms relating to the 
reproductive system. As has been noted, ovarian 
tenderness is a characteristic phenomenon, but there 
are other hysterogenic zones that are nearly, if not 
quite, as constant. Again, it is quite common to 
find marked tenderness over the corresponding 
regions in the male. The uterus is rarely involved, 
and the vaginal mucous membrane is not more 
frequently the seat of anesthesia or hyperesthesia 
than some other mucous membranes. The testicular 
tenderness spoken of by some authors is hardly 
characteristic enough to be placed in the category 
of hysterical stigmata. The point that has been 
raised, that in hysterical women there is an exces- 
sive discharge of mucus from the vagina, has not 
been borne out by observation. Again, while it has 
been shown that in hysteria it is not unusual to find 
certain disturbances in the sexual instincts, it is clear 
that these disturbances are central rather than per- 
ipheral. 

The reason why hysterical women refer so many 
of their ills to the organs of generation is because 
the hysterical mind is peculiarly open to suggestion, 
and the reproductive system, with its mysteries of 
menstruation and pregnancy, furnishes a most fruit- 



VISCERAL AND VASOMOTOR DISTURBANCES. 189 

ful field for suggestion. It is to be hoped that the 
clearer knowledge of the nature of hysteria will 
restrain the operative fury with which the past 
decad has become so familiar, and that the ovaries 
will no longer be removed to cure a disease which 
is resident in the higher cerebral centers. 

Disturbances of Respiration. — It is very com- 
mon to observe attacks of rapid respiration of mod- 
erate intensity occurring alone, or associated with 
other hysterical phenomena. Occasionally, however, 
this symptom becomes so pronounced as to consti- 
tute a veritable attack of what might be called 
" hysterical asthma." Charcot * has recorded a case 
in which the respirations numbered 180 a minute. 
In this case there was no evidence of cyanosis, and 
the pulse-rate was not disturbed. Weir Mitchell f 
relates a number of cases of hysterical rapid breath- 
ing, the respirations ranging from 60 to 150 a minute. 
The breathing in these cases was costal in type, 
superficial and without effort, and the pulse was not 
accelerated. 

The older writers, as Briquet, t described cases 
in which there were great dyspnea, abundant rales, 
cough, and profuse expectoration. As a rule, these 
attacks of hysterical rapid breathing come on in 
paroxysms and last several hours, terminating often 
in a convulsion or some other hysterical manifesta- 
tion, such as contracture or paralysis. Hysterical 
hemoptysis is a symptom occasionally observed, and 

* Op. cit., tome II. f Am. Jour. Med. Sci., 1893. % Loc. cit. 



190 HYSTERIA: ITS NATURE AND TREATMENT. 

is probably a part of the general vasomotor disturb- 
ance so common in hysteria. It is most frequently 
associated with a paroxysm of coughing, but may 
occur independently. The amount of blood lost is 
sometimes considerable, and the attacks may be re- 
peated at intervals. The main interest in this symp- 
tom is the diagnosis between this hysterical vaso- 
motor affection and a beginning pulmonary tubercu- 
losis. The older writers (Pomme) laid great stress 
upon this phenomenon, and probably confounded it 
with early tuberculosis. To-day, of course, such a 
mistake should be impossible. The hysterical cough 
has long been recognized, and ever since Sydenham's 
description of it has found a place in all treatises on 
hysteria. It is characterized by its hard, dry, parox- 
ysmal nature. It occurs in distinct attacks, of which 
as many as 30 or 40 may appear in a day. The 
paroxysm may last only a few minutes or may be 
prolonged for hours. A very diagnostic point is that 
these attacks never occur during sleep. Notwith- 
standing the frequency and often violence of the 
attacks, the patient is not, as a rule, exhausted by 
them ; and, as in hysterical rapid breathing, there is 
rarely any cyanosis. 

Hysterical expiratory spasm often mimics, in a 
curious way, the cries of animals. Examples of this 
are recorded in the account of the various early 
epidemics of hysteria (chap. 1). A case of this sort 
was recently under my care. A man of about 
thirty years of age, with no very marked hysterical 
stigmata, and apparently free from any distinct 



VISCERAL AND VASOMOTOR DISTURBANCES. 191 

mental disease, would, at intervals of five to fifteen 
minutes, sine a line or two in a high falsetto voice, 

o o 

terminating in a dozen or more sharp, shrill barks, 
not unlike the cry of an angry terrier. This con- 
dition had lasted for several months when I first saw 
him. Inspiratory spasm presents a large number of 
varieties. Among them may be mentioned hiccough, 
sobbing, sighing, yawning, and the like. Hysterical 
hiccough was apparently very common in the epi- 
demics of the middle ao-es, but does not seem to 

o ' 

have been noted often in modern literature. It 
comes on in paroxysms, and lasts for days, or even 
months, with little or no interruption. One case of 
hysterical hiccough that I saw in a young girl lasted 
for about a week and was cured by hypnotic sugges- 
tion. In a case of hysterical yawning, Charcot found 
that eight paroxysms occurred a minute, or 480 an 
hour. Hysterical sneezing is quite a common affec- 
tion, occurring in distinct paroxysms and generally 
provoked by some emotional cause. 

Affections of the Voice. — Hysterical aphonia, 
or loss of voice, — inability to speak in a loud tone, — is 
a very common hysterical manifestation, and has 
long been observed. Conversation is carried on in 
a low whisper, sometimes so low as to be almost 
inaudible. 

It is a well-known fact that many subjects of hys- 
terical aphonia, in whom the voice has sunk to a 
faint whisper, can sing as usual. Hysterical aphonia 
is occasionally accompanied by spasm or paralysis of 
the laryngeal muscles, but, as a rule, nothing can be 



192 HYSTERIA: ITS NATURE AND TREATMENT. 

made out from laryngoscopic examination. Prob- 
ably in- most cases there exists a certain amount 
of anesthesia of the laryngeal mucous membrane. 
Generally the duration of hysterical aphonia is short, 
but cases have been reported extending over months 
and years. In one of my cases the condition lasted 
many months. The voice was almost inaudible, 
and it was necessary to put the ear close to the pa- 
tient's mouth to hear what was said, and even then 
many words were lost. This patient recovered rap- 
idly under suggestion and the use of a strong fara- 
dic current applied to the larynx. Hysterical apho- 
nia must not be confounded with the much rarer 
condition of hysterical aphasia which has been seen 
in cases of hysterical hemiplegia. 

In this connection might be mentioned another 
variety of speech disturbance — hysterical mutism. 
There are, practically, only three conditions in which 
absolute loss of speech, or rather absolute mutism, 
occurs ; namely, hysteria, certain distinct mental af- 
fections in which there exist delusions respecting 
speech, such as melancholia and some forms of para- 
noia, and, thirdly, cases of simulation. 

In hysterical mutism there is never any evidence 
of the presence of a delusion, the patient apparently 
being simply unable to utter any sound. The lips 
will sometimes move but no sound will be produced. 
The onset of the affection is sudden and generally 
follows some emotional excitement. There rarely 
exists any paralysis of the tongue, lips, or laryngeal 
muscles. A case sent to me a few years ago was 



VISCERAL AND VASOMOTOR DISTURBANCES. 193 

that of a man of thirty-five years of age who had 
been entirely mute for several weeks. Upon being 
asked to talk he made grimaces, but was apparently 
unable to utter a sound, and carried a tablet upon which 
he wrote answers to all questions. He was taken to 
the electrical room, and in as suggestive a manner 
as possible a strong faradic current was suddenly 
applied to his larynx. The result was a scream, 
after which he began to talk. These cases some- 
times last for years, and recovery generally takes 
place suddenly, as in the case related above. 

Cardiac and Vasomotor Symptoms. — It is 
rather to be wondered at that the heart is not more 
frequently involved in hysteria than would seem to 
be the case, since this organ is so readily affected by 
disturbances of the higher centers. Perhaps in most 
cases of hysteria there is more or less cardiac dis- 
turbance, but it rarely becomes a prominent symp- 
tom. The most common symptom referable to the 
heart that is met with in hysteria is an unduly rapid 
pulsation. During the convulsive seizure this is 
most marked, and is often out of proportion to the 
physical exertion. The heart is easily excited in 
many hysterical subjects, and a very trivial cause 
may bring on an attack of hysterical tachycardia. 

An interesting illustration of this is seen in the 
report of a case by Dr. O'Donnovan.* A woman 
who had many hysterical stigmata, was subject to 
attacks of tachycardia, in which the heart would 



* Maryland Med. Jour., 1 889. 
17 



i 9 4 HYSTERIA: ITS NATURE AND TREATMENT. 

beat as many as 192 times a minute. These attacks 
lasted several hours, when the normal rate of pulsa- 
tion, 72, would be established. There was appar- 
ently always some emotional cause as the starting- 
point of the attacks, though the patient was not 
aware of any unusual sensations about her heart and 
seemed in no way incommoded by the condition. A 
careful physical examination of the heart in this case 
showed it to be perfectly normal. Whittaker calls 
attention to the fact that many substances, such as 
tea, coffee, tobacco, or alcohol, taken even in modera- 
tion, will greatly and unduly excite the hysterical 
heart. 

The other extreme, a slow heart, is rarely seen in 
hysteria, except in the state of lethargy already 
alluded to. Palpitation is met with but is not espe- 
cially frequent. The curious attacks of pseudo- or 
hysterical angina, in which there is great pain com- 
plained of in the region of the heart, and irregular 
pains in the extremities of the same side, have 
already been mentioned. 

Far more common than cardiac symptoms are the 
marked disturbances of the vasomotor system. In 
a mild degree these disturbances consist of sudden 
flushings of the face or upper part of the body, 
together with subjective sensations of heat or cold. 
These symptoms are usually fugacious, a patch of 
redness appearing suddenly, lasting but a few 
minutes, and disappearing. Sometimes there is an 
alternation of vasomotor paralysis and constriction, 
the appearance of the skin changing from red to 



VISCERAL AND VASOMOTOR DISTURBANCES. 195 

white. A condition which has often been noted is 
the so-called "autographism." In certain hysterical 
subjects a mark made with the finger-nail or the point 
of a pencil brings out a wide scarlet band which may 
persist for hours. This phenomenon played a con- 
spicuous part in the epidemics of hysteria seen in the 
middle ages. 

Mesnet* has recorded a very marked case of this 
condition, in which the line or word traced simply 
with the finger lasted for many hours. Occasionally 
the opposite condition of vasoconstriction has been 
noted, sometimes giving a distinct local asphyxia. 
The cold extremities, so often complained of by 
hysterical patients, are probably examples of vaso- 
constriction. Certain skin eruptions would seem to 
be sometimes associated in a casual way with hys- 
teria. Gilles de la Tourettef considers pemphigus 
to be the most characteristic of the cutaneous affec- 
tions allied with hysteria. The vesicular eruption of 
herpes seems in some manner to be related to hys- 
teria, and the same may be said of some of the forms 
of eczema. 

Weir Mitchell J has reported the case of a girl 
who, in addition to hysterical rapid breathing and 
other marked stigmata, had a peculiar eruption on 
her leg. Duhring, commenting on this case, de- 
scribes the lesion as a crust made up of epithelium, 
and places it in the.category of trophic manifestations, 
due to some general disturbance of the central ner- 

* Gaz. des Hop., 1889. f Loc. at. j Loc. cit. 



196 HYSTERIA: ITS NATURE AND TREATMENT. 

vous system. More striking still are the cases of 
hysterical gangrene, of which a large number have 
now been reported (Kaposi, Hebra, Neumann, and 
others). This affection is seen in young females, 
and begins as a painful spot on the skin about the 
size of a dollar. In a few hours the skin over the 
painful area becomes gangrenous, and after a couple 
of weeks the slough separates, leaving a character- 
istic hypertrophied cicatrix. These ulcers recur at 
irregular intervals for months or years. 

Hysterical Edema. — A vasomotor phenomenon, 
which was in all probability recognized by Syden- 
ham, but which has only been studied carefully since 
the observations of Charcot in 1889, is hysterical 
edema. This rare affection develops rather sud- 
denly in young persons, in whom, as a rule, there 
are other hysterical stigmata. Usually only one 
side is involved, though the disease may attack both 
lower extremities. There may be no sensory dis- 
turbances, but it is generally the case that a certain 
degree of anesthesia is present, and sometimes 
♦hyperesthesia. The skin presents either a dead 
white color, the white edema, or may be reddish or 
bluish in tint, blue edema. The parts affected are 
firm to the touch, and there is rarely any pitting on 
pressure. The increase in the size of the limb or 
other part involved is often very considerable. The 
edema is sometimes associated with paralysis, as 
in the interesting case related by Weir Mitchell.* 

* Am. Jour. Med. Sci., 1884. 



VISCERAL AND VASOMOTOR DISTURBANCES. 197 

Several cases of this nature were reported by 
Mitchell under the title of "unilateral swelling," 
and antedate the observations of Charcot. It was 
noted by Mitchell that in his cases the swelling was 
most marked near the menstrual period, or after 
some emotional excitement. The skin showed no 
change in color or temperature. 

McCosh * reports the case of a woman in whom, 
after attacks of hysterical convulsions, a blue edema 
involved the breast, arm, and forearm of one side. 
The skin was of a bluish tint, cold, and hyperesthetic. 
Later the case developed what would seem to have 
been hysterical gangrene or ulceration. A further 
study of this case was made by Shaw, -j- I have 
notes of one case of hysterical edema occurring in 
a lad of fifteen. Both leo-s were involved from the 
knees down, the edema being firm, not pitting on 
pressure, and the skin dead white. The boy stated 
that he was subject to these attacks and that his 
mother also had them at times. The duration of 
hysterical edema is variable, but usually lasts for 
some months. 

Excessive sweating, associated with distinct hyster- 
ical symptoms, was noted by Sydenham. This 
sweating may be either local or general, and is 
sometimes preceded by a cold stage, as in the case 
related by Sorbets.J In rare instances there may 
occur a veritable . sweating of blood — hemidrosis. 



Annals of Surgery, 1893. f Brooklyn Med. Jonr., 1893. 

% Gaz. des Hop., 1889. 



198 HYSTERIA: ITS NATURE AND TREATMENT. 

While many of the cases occurring in the epidemics 
of the middle ages were rank deceptions, made easy 
by the religious superstition of the period, still there 
can be no doubt of the fact that the phenomenon of 
hemidrosis does really take place, since every pre- 
caution to prevent fraud has been exercised. The 
condition is seen only in hysterical subjects, and 
certainly belongs to the vasomotor disturbances of 
this disease. 

Up to very recent times it was claimed that mus- 
cular atrophy never occurred in hysteria, and when 
it was present was an absolute proof of some organic 
affection, or at least did not in any way connect itself 
with hysteria. The recent observations of the French 
school have proven indubitably that a slight degree 
of muscular atrophy not very infrequently occurs in 
hysteria. As a rule, the atrophy takes place in a 
paralyzed or contractured limb, the paralysis or con- 
tracture being, of course, of hysterical origin, and 
involves the muscles, not by individual groups but 
generally. Babinski * sums up the characteristic 
features of hysterical muscular atrophy as follows : 
" (1) The atrophy differs in degree in different cases, 
but may be very well marked. (2) There are no 
fibrillar contractions. (3) The idiomuscular excita- 
bility is normal. (4) The electrocontractility may 
be diminished, but there is no distinct reaction of 
degeneration. (5) The atrophy often develops with 
great rapidity, and its disappearance is equally 

* Arch, de Neurol., 1886. 



VISCERAL AND VASOMOTOR DISTURBANCES. 199 

sudden." Sometimes there are sensations of ting- 
ling or even pain over the affected limb. 

In general it will be noted that the trophic manifes- 
tations of hysteria are very slight, so indistinct in 
fact that they have received but a tardy and qualified 
recognition. It is certain, however, that trophic dis- 
turbances do occur in hysteria, and are related in a 
casual manner to the neurosis. The great difficulty, 
of course, is in excluding all other causes which 
might affect nutrition, and as we now know these 
causes are many and diverse. 

Even in cases that go to autopsy there may still 
remain a doubt as to whether some lesion has not 
been overlooked, as in the case of extreme muscular 
atrophy reported by Hirt* occurring in a young girl 
who was a pupil in a school where there was an epi- 
demic of hysteria. The autopsy in this case re- 
vealed nothing, and the diagnosis was made, as it 
were, "in default." Our knowledge of the interrela- 
tion existing between the higher and lower centers 
is still uncertain, and until this uncertainty is resolved 
it is manifestly impossible to say what effect a gen- 
eral disturbance of the nutrition of the cells consti- 
tuting the higher centers may have upon the nutri- 
tion of the cells of the lower centers, and conse- 
quently upon the tissues which look to these lower 
centers for the stimulus necessary to keep up a 
healthy action. 

Hysterical Fever. — A subject of great interest 

* Deutsche Med. IVoch., 1 894. 



200 HYSTERIA : ITS NATURE AND TREATMENT. 

which might be considered in this connection is hys- 
terical pyrexia. In considering this subject there 
are two questions that naturally arise. First, is it 
possible to have any considerable rise of tempera- 
ture, which is due solely to some disturbance in the 
heat-regulating apparatus ? and second, are the 
recorded clinical observations free from error ? have 
all other possible causes which might be opera- 
tive in inducing fever been rigorously excluded ? 
Without going into the physiological discussion of 
the subject, the first question, namely, whether the 
bodily temperature may be raised by disturbances 
of the higher centers, may be answered in the 
affirmative. Passing to the clinical consideration of 
the subject we find, among the older writers (Pomme, 
Sydenham, Whytt), descriptions of hysterical fever, 
but it is doubtful whether these observations should 
be received as exact, since the etiology of fever was 
far from clear at that day, and certain causes which 
are now well known to be active in the production 
of fever were not recognized and consequently not 
excluded. 

Recent literature on hysteria contains frequent 
reference to hysterical pyrexia, and the condition 
would perhaps obtain still further recognition if 
clinical observation were more frequently directed 
to this symptom. One is rather surprised to find, 
in looking through Richer's classic work, how rarely 
the thermometer was used. Briquet* frequently 



Op. cit. 



VISCERAL AND VASOMOTOR DISTURBANCES. 201 

refers to cases of hysterical pyrexia and considered 
it a not infrequent symptom. Gilles de la Tourette * 
states, on the other hand, that the condition has 
never been seen at the Salpetriere. One of the 
most exhaustive papers on the subject is that of 
Sarbo, of Budapesth. -f His conclusions are as fol- 
lows : (1) There is a genuine hysterical fever which 
may be (a) continuous and (b) paroxysmal. (2) 
Hysterical fever is a functional fever. (3) It occurs 
either in simple hysteria or in hystero-epilepsy. 
In the elaboration of these conclusions, the author 
describes first a form of pseudohysterical fever, in 
which are present tachycardia, vasomotor disturb- 
ances, headache, thirst, and other symptoms of fever, 
with no actual rise of temperature; and second, true 
fever, which may present itself as a continued or as 
an intermittent, irregular, or paroxysmal symptom. 

There was recently under my care a very good 
example of the first type : a young woman of a 
marked hysterical temperament, without any very 
decided stigmata, presenting all the phenomena of 
fever without any actual rise of temperature. The 
pulse ranged from 120 to 160, respiration was rapid, 
skin dry, face rather flushed. The organs of circu- 
lation and respiration, as in fact all the organs of 
the body, were apparently perfectly normal. This 
condition continued a week or more, with no rise of 
temperature, and then disappeared. The continued 
fever may be mild or severe ; it has no settled type ; 



cit. f Arch, fur Psychiat., Band XXIII, 2. 

18 



202 HYSTERIA : ITS NATURE AND TREATMENT. 

it may appear and disappear suddenly. Differences 
in the temperature of the two sides of the body 
are often observed, and there may be morning 
and evening variations. The fever may follow, but 
is independent of convulsive attacks. Pucci* con- 
cludes: (i) That there is a true hysterical fever. 
(2) It generally follows other hysterical symptoms, 
yet it may be the first symptom of hysteria. (3) It 
always accompanies other symptoms of hysteria, 
which may become aggravated during the period of 
the highest temperature. (4) It may assume the 
quotidian or tertian intermittent type, or the remit- 
tent or subcontinuous type. (5) It is accompanied 
by the ordinary symptoms of fever, and may rise to 
a high degree, and during the apyrexia the tempera- 
ture may fall to 95 ° F. (6) The fever may undergo 
notable interruptions of days or months. (7) Nu- 
trition remains good, but the mental condition may 
be disturbed. (8) The fever is refractory to anti- 
thermic remedies. Debovef calls attention to the 
irregularity of the fever, its long duration and in- 
tensity, and the fact that there is no evening exacer- 
bation. This author states that he has been able to 
raise the temperature 2.7 F. by hypnotic suggestion. 
Bressler J calls attention to the irregularity of the 
fever, both as regards duration and intensity. Many 
more authorities might be cited, but enough have 
been given to prove conclusively the existence of 



* Gazetta degli Ospitali, No. 91. 

| Gaz. Hebdom., Feb., 1885 ; May, 1886. % Med. Ret 



VISCERAL AND VASOMOTOR DISTURBANCES. 203 

hysterical pyrexia. It may be said, in passing, that 
there have appeared recently reports of several 
cases of extreme hyperexia which were supposed to 
be of hysterical origin. One of these at least (the 
Omaha case), and probably all of them, were palpa- 
ble frauds. 

It is to be noted, that during the progress of hys- 
terical pyrexia there is comparatively little disturb- 
ance of nutrition, and the urine, while showing a 
slight decrease in solid constituents, is not altered to 
anything like the degree observable in fevers due to 
a distinct cause. A point of some practical value, 
which has not been dwelt upon by the various writers 
on this subject, is that in cases of fever from various 
causes, hysteria may incidentally occur and change 
the type and intensity of the disease. This, of course, 
would apply only to the very first period of the 
pyrexia. It has already been mentioned that a rise 
of temperature has been obtained by hypnotic sug- 
gestion. In one experiment upon an hysterical 
woman, I was able to raise the temperature one 
degree F. by non-hypnotic suggestion. It is not to 
be wondered at that in hysterical persons fearing or 
expecting some fever, puerperal or malarial for ex- 
ample, autosuggestion acts upon the thermic centers. 
There can be no doubt of the fact that hysterical 
pyrexia is' very rare, but it is certain that the condi- 
tion exists. 



CHAPTER VIII. 
DIFFERENTIAL DIAGNOSIS. 

It may be stated, without fear of contradiction, 
that the diagnosis of hysteria is very often difficult, 
and should never be made without careful considera- 
tion. The recognition of hysterical symptoms is so 
easy and plain that even a layman does not hesitate 
to pronounce upon them, but this is far removed 
from a true diagnosis. The question should always 
arise, is hysteria responsible for all the symptoms ? 
or, as Weir Mitchell has so graphically put it," Are 
the symptoms merely painted upon an hysterical 
background ?" 

A quarter of a century ago hysteria was not so 
generally recognized as now, or at least the charac- 
teristic stigmata were not as familiar as they have 
since become, and the most common mistake was to 
regard these stigmata as evidences of grave organic 
lesions of the central nervous system. To-day it is 
quite as common a mistake to hasten to the diagno- 
sis of hysteria after meeting some familiar and classic 
symptom. Take, as an illustration, a case recently 
under my care in the City Hospital : a woman with 
hemianesthesia very well marked, besides other stig- 
mata, which were cured by suggestive treatment, 
but with well-marked kidney disease, as the autopsy 

showed. In this case there was a very puzzling 

204 



DIFFERENTIAL DIAGNOSIS. 205 

symptom ; this was obstinate vomiting without any 
gastric disease. The question — and it was an ex- 
tremely difficult one — was, whether to attribute the 
vomiting to hysteria or to the kidney disease which 
at first was not well marked. 

Multiform in its symptomatology, and wonderful 
in its mimicry, hysteria must yet be regarded as a 
distinct entity, attended by constant and characteris- 
tic manifestations. Hence it becomes necessary to 
separate it clearly from certain neuroses with which 
it is sometimes confounded. In the first place, the 
old fallacy, which has wrought such great injustice 
to the victims of hysteria, namely, that all hysterics 
were necessarily impostors, is now happily banished. 
Traces of it linger, however, in regions remote from 
the light of the newer science. It may be safely 
said, that no physician who has taken the time and 
trouble to intelligently study a single case of well- 
marked hysteria has ever come away from such in- 
vestigation without being convinced that hysteria is 
a reality. Imitative as the disease is itself, it can 
rarely be successfully feigned. The true hysteric is 
far more apt to be mistaken for a malingerer than is 
the impostor to be confounded with the victim of 
this peculiar malady. 

Owing to a faulty conception of the nature of 
hysteria and an imperfect acquaintance with its 
complex symptomatology, the error is often made 
of using the terms hysteria and neurasthenia syn- 
onymously. There is no need here to do more 
than call attention to the fact that the well-marked 



206 HYSTERIA : ITS NATURE AND TREATMENT. 

stigmata of hysteria are practically entirely wanting 
in neurasthenia. This latter term is used rather 
loosely to indicate a general condition of want of 
tone, debility, exhaustion of the central nervous 
system. It has no very well-marked stigmata, such 
as anesthesia, contracture, paralysis, and the whole 
character and course of the disease, together with 
its mode of onset, differ widely from hysteria. Con- 
trast, for example, the clear-cut motor or sensory 
manifestations in hysteria with the very general 
muscular fatigue and the indefinite and shifting sub- 
jective sensations of neurasthenia. The two diseases 
are probably related, both in their etiology and 
pathology, and unquestionably sometimes blended. 
When this happens, it is not very difficult to pick out 
the symptoms peculiar to each affection. Another 
condition with which it is common to confound hys- 
teria is hypochondria. There is far less excuse for 
mistaking this affection for hysteria than for confus- 
ing hysteria and neurasthenia. The older writers 
are probably responsible for the confusion, since they 
were accustomed to regard hypochondria as a sort 
of male hysteria. Their conception of hysteria, as 
implied in its name, did not allow them to assign it 
to the male, and hence the term hypochondria had to 
do duty for both diseases. 

Hypochondria being distinctly a mental disease 
with peculiar delusions and no true stigmata, differs, 
of course, widely from hysteria and should never be 
confounded with it. As in the case of neurasthenia, 
it may sometimes be combined with hysteria, making, 



DIFFERENTIAL DIAGNOSIS. 207 

by the way, an extremely intractable disease. There 
is a certain condition, seen both in men and women, 
that has never received any name and is generally 
alluded to as "general nervousness." It partakes 
slightly of the nature of the three conditions just 
mentioned — sometimes the symptoms of one, some- 
times of the other, predominating. The mental 
condition is rather hypochondriacal, and the somatic 
stigmata are inconstant, now showing the general 
hyperesthetic phenomena of neurasthenia, again 
recalling hysteria by the zonal distribution of the 
points of tenderness or impaired sensation. This 
hybrid affection is by no means uncommon ; its 
course is extremely chronic, and the efforts at treat- 
ment are often very ineffectual. One often sees a 
condition among women of the higher walks of life 
which is wrongly called hysterical. This condition 
is characterized by a general inertia, usually mental 
but sometimes physical, yet without the distinguish- 
ing features of neurasthenia. The subjects declare 
that they have lost interest in their daily amuse- 
ments, and they greatly enjoy being on the sick-list. 
They are not malingerers exactly, but are simply 
victims of ennui. Sometimes through inheritance, 
but more often as the result of a purposeless life, 
there has come to them a weakened volition and a 
certain state in which suggestion is all too readily 
accepted and acted upon. Their emotional natures 
are often in an exalted state, their likes and dislikes 
greatly intensified, and their views of life tinged 
with pessimism. This condition, which is, of course, 



208 HYSTERIA : ITS NATURE AND TREATMENT. 

a very general one and not to be classified or even 
described with any accuracy, is mentioned here 
because it is very commonly spoken of as hysterical. 
Bearing in mind the characteristic features of hys- 
teria, it will be seen that this and similar states are 
not to be included under the name hysteria. They 
bear, of course, some general similitude to certain 
of the milder mental manifestations of hysteria but 
lack the important stigmata. 

It may be said that the diagnosis of hysteria 
should never be made with certainty without the 
presence of some of the well-known somatic stig- 
mata, such as anesthesia, hyperesthesia, paralysis, 
contracture, special sense disturbances, and the like. 
One may suspect the approach of the disease from 
certain indistinct mental states, but there can be no 
certainty before the advent of some of the charac- 
teristic objective symptoms. While the wealth and 
variety of the symptoms of hysteria constitute an 
aid to its diagnosis, as Lloyd has said, it is no less 
true that the disease may be monosymptomatic, and 
it is in this latter case that the differentiation between 
it and some disease of widely different nature must 
be made. Nor does this apply only to diseases of 
the nervous system, — paralyses, anesthesias, and the 
like, — but to many general acute and chronic com- 
plaints. Consequently, it is a rule from which there 
should be no deviation, that a diagnosis of hysteria 
should never be made until after a careful, compet- 
ent, and thorough physical examination. A sup- 
posed hysterical head pain may be due to brain 



DIFFERENTIAL DIAGNOSIS. 209 

tumor, or what was regarded as an abdominal hys- 
terogenic zone may in reality prove to be a serious 
disease of some of the viscera of this cavity. 

In the foregoing pages the endeavor has been 
made to point out, as clearly and concisely as possi- 
ble, the salient features of the various symptoms of 
hysteria, without attempting in each instance to 
indicate the differential diagnosis. At the risk of a 
certain amount of repetition, it is purposed now to 
take up, seriatim, the more important stigmata of 
hysteria, and briefly separate them from the condi- 
tions they most resemble. 

Anesthesia. — The diagnosis of the wide-spread 
disturbances of sensation — hemianesthesia or, the 
much rarer, total anesthesia — is not difficult, since 
this form of sensory involvement occurs practically 
only in hysteria. Of course, it is possible to have a 
hemianesthesia of cerebral origin, due to lesion in 
the capsule, and such cases have been reported 
(Charcot). The same author has also called atten- 
tion to the fact that hysterical hemianesthesia and 
hemianesthesia of cerebral origin often perfectly 
correspond. Of course, there are practically always 
certain accompanying symptoms peculiar to each 
condition. For example : in favor of hysteria would 
be the age of the patient, the mode of onset, the 
exact limitation to one side of the body, the very 
common involvement of the special senses, the zones 
of hyperesthesia which are nearly always present, 
and the course of the case. In hemianesthesia of 
cerebral origin the anesthesia is hardly so regular ; 



210 HYSTERIA: ITS NATURE AND TREATMENT. 

there are irregular motor symptoms which do not 
correspond with the hysterical paralyses ; the special 
senses are rarely involved, and the onset and course 
of the case differ widely from the functional disease. 
General anesthesia of cerebral origin, which, as stated 
above, is conceivable, need not be considered. The 
wide-spread anesthesia of peripheral neuritis, and 
the sensory disturbances of syringomyelia and other 
cord lesions, with their irregular distribution of anes- 
thesia, altered reflexes, and marked trophic disturb- 
ances, can never be confounded with hysteria. 

Hysterical anesthesia involving one limb, or scat- 
tered in patches over the body, may resemble a 
limited neuritis or a cord lesion, but here again the 
marked symptoms of these latter diseases are too 
characteristic to be overlooked. Toxic neuritis, — 
poisoning from lead, arsenic, alcohol, and the like, 
— is to be borne in mind, since in these conditions 
the anesthesia is often wide-spread, and in two of 
the affections, notably, — arsenical and alcoholic poi- 
soning — hysterical symptoms are curiously frequent. 
It should not be forgotten that in many mental dis- 
eases there may be distinct anesthesia. Of the 
special senses, the only one in which disturbances 
likely to be confounded with other conditions occur, 
is vision. 

Hysterical amblyopia presents one symptom which 
is almost pathognomonic ; namely, anesthesia of the 
conjunctiva and often of the cornea as well. This 
symptom is of great value, since amblyopia from 
other causes — as, for example, toxic amblyopia — 



DIFFERENTIAL DIAGNOSIS. 211 

may come on almost as suddenly as the hysterical 
form. It is extremely unusual to have hysterical am- 
blyopia without a corresponding anesthesia of the skin 
of the same side. The restriction of the visual field 
in hysteria is regular and concentric, with a reversal 
of the color fields, as has been pointed out in detail, 
and there is rarely any impairment of visual acuity. 
There can be no doubt, as Charcot has shown, that 
it is possible to have amblyopia, with restriction of 
the visual fields, from a lesion in the internal capsule. 
Disturbances of the visual fields accompanying cord 
lesions, such as multiple sclerosis, syringomyelia, or 
locomotor ataxia, need merely to be mentioned, since 
although they resemble somewhat the similar con- 
dition seen in hysteria, there is nearly always distinct 
alteration of the optic nerve or retina. Involvement 
of the eye muscles in hysteria is so uncommon that, 
with one exception, the subject need not be men- 
tioned in this place. The exception to the rule is 
hysterical blepharospasm, due to a contracture affect- 
ing the orbicularis. The accompanying anesthesia, 
together with the fact that there is nearly always 
paralysis or contracture of muscles elsewhere, usually 
makes the diagnosis clear. When the hysterical 
nature of this condition is merely suspected and 
cannot be distinctly made out, some suggestive 
treatment should be employed. It may be said, that 
a number of cases of hysterical blepharospasm have 
been operated on under a mistaken idea, of course, 
of their nature. 

Hyperesthesia. — When there is present a gen- 



212 HYSTERIA: ITS NATURE AND TREATMENT. 

eral hyperesthesia, or where there are large areas 
of the cutaneous surface involved, the diagnosis 
presents no special difficulty. One may, perhaps, 
sometimes think of polyneuritis or spinal meningitis, 
but the resemblance of these latter to hysteria is 
never very close. The localized hyperesthesias are 
sometimes strongly suggestive of organic disease. 
The pseudomeningitis of the French school is often 
singularly like the genuine disease, and, as Chant- 
messe * says, " Only the knowledge of the antece- 
dents of the subject, the existence of disturbances 
of sensation that can be referred to hysteria, the 
temperature which does not rise above normal, per- 
mit us to suspect the neurosis, and warn us to 
reserve our diagnosis." A case of this nature re- 
cently under my care, was so puzzling that I was 
entirely unable to make up my mind as to whether 
the symptoms were due to hysteria alone or to 
organic disease complicated by hysteria. The re- 
covery of the patient without any trace of paralysis 
pointed to the former supposition. 

Hysterical arthritic affections often simulate very 
closely organic disease. Since the recent careful 
study of infantile hysteria, it has been shown that 
Pott's disease, in its early stages, is closely mimicked 
by hysteria. The differential points are that in hys- 
teria there is no actual deformity of the vertebral 
column, no evidence of cord involvement, and the 
pain is generally greater upon light friction upon the 



Thesis," Paris, 1884. 



DIFFERENTIAL DIAGNOSIS. 213 

skin than from deep pressure over the spines of the 
vertebrae. Hysterical coxalgia, in like manner, pre- 
sents a superficial rather than a deep hyperesthesia. 
There is a triangular area of hyperesthesia, with the 
apex about the pubis and the base over the sacrum. 
The gait is an exaggeration of the gait of the 
organic affection, though in many instances it closely 
resembles it. The employment of an anesthetic 
gives rather negative results, though, as Charcot* 
has pointed out, the contracture reappears before the 
hyperesthesia, reversing the order of the reappear- 
ance of the symptoms after narcosis in the organic 
affection. An acute observation of Brodie'sf is 
that the nocturnal crisis of pain, which awakens the 
patient and which is such a familiar and distressing 
symptom in the genuine coxalgia, is not observed in 
the hysterical form. In the case of the other joints, 
as the knee or elbow, there is the same geometrical 
arrangement of the superficial hyperesthesia, with 
usually absence of heat and redness. There may 
be actual swelling, or the contracture of the muscles 
may closely simulate it. In general, whatever joint 
be involved, it constitutes a veritable hysterogenic 
zone, and light friction upon the skin covering it 
will produce a modified hysterical paroxysm. A 
very slight degree of muscular atrophy may some- 
times attend the hysterical arthralgias, but not com- 
parable to what is seen in the organic cases. 

The hysterical breast, described by many of the 

* Op. at. I Op. at. 



2i 4 HYSTERIA: ITS NATURE AND TREATMENT. 

older writers (Willis, Pomme, Astley Cooper), must 
be differentiated from organic inflammatory condi- 
tions by the general absence of heat and redness, 
though sometimes there is a bluish tint of the skin 
in the hysterical cases. It often resembles tumor, 
and not infrequently has been operated on as such. 
In doubtful cases, it is impossible to do more than 
suspect, from the general appearance of the case, its 
nature, and watch the course of the supposed tumor 
or inflammation and the effects of suggestive treat- 
ment. 

Motor Disturbances. — Hysterical tremor may 
be present during repose, or develop only on in- 
tentional movements. It exists under two forms, as 
has been pointed out, the slow and rapid types. In 
general, hysterical tremor must be differentiated 
from toxic tremors, and tremors due to some brain 
or cord lesion. The resemblance between hysterical 
tremor and the toxic tremors caused by lead, mer- 
cury, alcohol, and some other substances, is often very 
close, and this likeness is heightened by the frequent 
existence of anesthesia in the latter affections. The 
anesthesia, however, in the toxic tremors follows in 
general the course of the peripheral nerves, and 
rarely has the geometric distribution that is seen to 
be so characteristic of hysterical anesthesia. Again, 
in the tremors due to metallic or other poisoning, the 
reflexes are greatly altered, the electrocontractility 
is, as a rule, abolished, and muscular atrophy is more 
or less pronounced. The tremors associated with 
organic lesion of the cord or brain, multiple sclero- 



DIFFERENTIAL DIAGNOSIS. 215 

sis, paralysis agitans, or post-hemiplegic conditions^ 
together with choreiform affections, while some- 
times more or less closely resembling hysterical 
tremors, present, usually, pathognomonic symptoms, 
and the only question to be decided is, as to whether 
hysteria exists along with the organic disease. 

Hysterical contracture may, as has been pointed 
out, be general, the diathesis of contracture, or may 
affect one or more limbs. The former condition 
could only be confounded with Thomsen's disease 
or tetany. The resemblance is not close enough to 
the former rare disease to deserve notice, and in 
the case of the latter the peculiar form of the con- 
tracture is almost pathognomonic. It is also not at 
all certain that hysteria does not play a part in the 
etiology of tetany. Contracture of the extremities, 
one or more, may resemble contracture from injury 
to the peripheral nerves, injury to the structures of 
the joint, or contracture following brain or cord 
disease. In general, the diagnostic points of hys- 
terical contracture are the suddenness of the onset, 
the accompanying anesthesia, the very slightly 
altered reflexes, the absence of marked muscular 
atrophy, the sudden changing of form upon using 
force to overcome the contracture, the disappearance 
of the contracture after the application of the Es- 
march bandage, or upon the administration of an 
anesthetic. 

It is a curious fact that an hysterical contracture 
very rarely shows, under narcosis, any fixation of 
the joint. Old contractures of many months' or 



216 HYSTERIA: ITS NATURE AND TREATMENT. 

even years' duration, are perfectly relaxed by an 
anesthetic, and this is an important diagnostic point. 
Cases of hysterical contracture have been reported 
in which there was some fixation of the joint, but 
such cases are exceptional and always suggest the 
possibility of the hysteria having been grafted upon 
an injury. 

Hysterical paralysis of the monoplegic, hemi- 
plegic, paraplegic, or quadruplegic type differs very 
markedly from organic paralysis, and presents the 
following characteristic features : the mode of onset, 
the peculiar forms of anesthesia, unaltered reflexes, 
electrocontractility and nutrition, absence of the 
girdle sensation in the paraplegic form, with no 
involvement of bladder or rectum : in the hemiplegic 
form the facial muscles are not involved, or at least 
this accident is extremely rare ; the leg is more par- 
alyzed than the arm, and the gait in walking is drag- 
ging and does not show the outward rotation of the 
leg which is so characteristic of organic hemiplegia. 
The course of the paralysis differs in that the symp- 
toms of hysterical paralysis suddenly reach their 
maximum, while in many forms of organic paralysis, 
as in peripheral and spinal cord lesions, a consider- 
able period elapses before the maximum is attained. 
Again, the contracture in the hysterical variety 
comes on at once, thus differing from a paralysis of 
cerebral origin. It is by no means easy to tabulate 
the points of diagnostic differentiation which exist 
between hysterical and other convulsive seizures. 
As has been shown, there are many grades of what 



DIFFERENTIAL DIAGNOSIS. 



217 



may be called hysterical convulsions. The typical 
grand attack, or major hysteria, has, practically, to 
be differentiated but from one condition ; namely, the 
grand mat of epilepsy. 

A comparison between the two conditions shows 
the following salient points of differentiation : 



HYSTERIA. 

1. Often some exciting cause for 
the attack, such as grief, anger, emo- 
tional excitement. 

2. An aura, consisting of globus 
hystericus, subjective sensations, etc., 
is common. 

3. The attack occurs during the 
day. 

4. Loss of consciousness is gradual 
and not always complete. 

5. The patient is rarely hurt in 
falling, but rather sinks down than 
falls, and does not bite the tongue or 
pass urine or feces involuntarily. 

6. The range of the clonic move- 
ments is wide. 

7. The return to perfect conscious- 
ness is rapid after the conclusion of 
the attack. 

8. There is no alteration of tem- 
perature. 

9. The duration of the attack is 
half an hour or longer. 

10. The urinary solids are de- 
creased. 



EPILEPSY. 
1. Usually no exciting cause. 



2. The aura is different in char- 
acter and not so common. 

3. The attacks occur very fre- 
quently at night. 

4. Loss of consciousness is always 
sudden and complete. 

5. The patient is very often in- 
jured by the fall ; bites the tongue 
and often passes urine and eces n- 
voluntarily 

6. The range of the clonic move- 
ments is of slight extent. 

7. The attack is very generally fol- 
lowed by a heavy sleep or some mental 
disturbance. 

8. Not infrequently there is a dis- 
tinct rise of temperature. 

9. The duration of the attack is 
never more than five to ten minutes. 

10. The urinary solids are in- 
creased. 



As a matter of practice, the physician has very 
often to make his diagnosis from a description of the 
attack, and not from personal observation of it, and 
the points to be inquired into specially are the hys- 
terical antecedent symptoms, the exciting cause, the 



218 HYSTERIA: ITS NATURE AND TREATMENT. 

duration of the attack, the passage of urine during 
the paroxysm, the biting of the tongue, and the 
nature of the movements. 

As a rule, fairly clear answers may be expected to 
these questions. The fact that the hysterical patient 
usually requires an audience is a valuable, though 
not an absolute, diagnostic point. 

The irregular, abortive, or incomplete hysterical 
convulsive attacks may sometimes be mistaken for 
uremia, brain lesions, the delirium of fever, or pois- 
oning from certain substances. There is never any 
real difficulty in the differential diagnosis between 
hysteria and the conditions just mentioned, for the 
hysterical element, especially the psychic manifesta- 
tions, soon becomes evident, and the symptoms of 
the various affections mentioned should be apparent 
after careful examination. There is a phase of the 
hysterical attack that may resemble petit mal rather 
closely, and this condition has not been sufficiently 
insisted upon. The patient will describe a certain 
momentary loss of consciousness with or without sub- 
jective sensations of tingling, numbness, or tightness 
across the chest. Vertigo is often one of the symptoms 
of this minor attack. The diagnosis is to be made 
from the fact that there is no absolute loss of con- 
sciousness, no change in the countenance, and the 
minor hysterical attack is usually associated with 
certain unmistakable psychic manifestations either 
preceding or following the attack. Enough, per- 
haps, has been said in another chapter in regard 
to the mental condition in hysteria to differentiate 



DIFFERENTIAL DIAGNOSIS. 219 

it from insanity. The peculiar and characteristic 
emotional disturbances, the states of exaltation and 
depression rapidly following each other, the tendency 
to exaggeration, the absence of any distinct delu- 
sions, the attendant somatic stigmata, — all these 
manifestations present a picture that is sufficiently 
clear. It is true, however, that now and then cases 
are seen that can with difficulty be distinguished 
from acute mania, and others from acute melancholia. 
Such cases should be studied with great care and 
watched for a considerable time, since the commit- 
ment of such patients to an asylum as insane often 
has a very bad effect. 

The visceral and vasomotor manifestations of 
hysteria are of importance, and are often con- 
founded with organic disease. Disturbances of the 
circulatory, respiratory, and digestive systems often 
closely simulate organic affections, but can be differ- 
entiated, practically with ease, by the negative re- 
sults of a careful physical examination, taken to- 
gether with the presence of hysterical stigmata 
affecting other parts of the body. 

Attention has been called to the fact that hysteri- 
cal affections of the various viscera are attended 
only by subjective sensations, and the presence of 
distinct physical signs of disease is proof positive 
that the' condition is not merely hysterical. In re- 
gard to the stomach, for instance, it has already been 
pointed out that hysterical vomiting is unattended 
by any distinct digestive changes, and in hysterical 
ischuria the urine obtained shows no abnormal in- 
gredient. 



220 HYSTERIA: ITS NATURE AND TREATMENT. 

In general, it may be said that the diagnosis of 
hysteria rests upon negative, no less than positive, 
symptoms. We must be certain that the symptoms 
complained of cannot be due to any recognized le- 
sion, and to this must be added the characteristic 
stigmata of the neurosis. Finally, the whole life- 
history of the individual must be viewed ; the hered- 
ity, the environment, the education, the mode of life, 
and the emotional causes that might be responsible 
as exciting causes. It will thus be seen that the ex- 
amination of a case of hysteria carries the observer 
over a very wide field, and demands thorough, pains- 
taking, and conscientious work if a certain diagnosis 
is to be arrived at. 



CHAPTER IX. 
TREATMENT. 

In considering hysteria, whether from the stand- 
point of diagnosis or of treatment, the fundamental 
idea is that the disease has its seat in the higher 
centers of the brain, and that the bodily manifesta- 
tions — anesthesia, hyperesthesia, contractures, par- 
alysis, and like symptoms — depend for their exist- 
ence upon the imperfect working of these higher 
centers. Again, it is evident that heredity plays a 
very important part in the etiology of hysteria, as it 
does in so many mental affections. This heredity 
may be direct or indirect, for the hysterical parent 
may transmit hysteria to the offspring, or may hand 
down only a neurotic taint, a predisposition to this 
or other nervous disease. Hence it will be seen, 
that the prevention of hysteria in persons who are 
predisposed to it should claim the careful considera- 
tion of the physician. 

It is often difficult to assign the relative import- 
ance to heredity and environment, and this is par- 
ticularly true in the case of hysteria. We know, as 
has just been said, that heredity is an extremely 
important factor i.n the etiology of hysteria, but per- 
haps due importance has not been assigned to the 
influence of environment. The daughter of an hys- 
terical mother starts in life, it is true, with a nervous 



222 HYSTERIA: ITS NATURE AND TREATMENT. 

system which by inheritance is predisposed to hys- 
teria, but it is to be doubted whether this factor is 
any more important than the constant association 
with the hysterical parent. Environment, with all 
that the term implies, acts upon the hysterical mind 
through suggestion, and it has been shown that 
suggestion runs through all the symptomatology of 
hysteria. It is the strongest bond which connects 
the two closely related conditions — hysteria and the 
hypnotic state. Thus the child of an hysterical 
mother is a constant witness of the emotional out- 
bursts and hysterical crises, and these displays must, 
of necessity, influence its developing mind. In no 
way are children bound to their parents more closely 
than through their emotions. A weeping mother 
will soon have her little ones around her in tears, 
although they may be totally ignorant of the cause 
of the maternal grief. The unwholesome emotional 
atmosphere, the sudden change from tragedy to 
comedy, the sensationalism, the sentimentality of 
the hysterical household, are certainly equally as 
responsible, if, indeed, not more responsible, for the 
development of hysteria than pure heredity. 

These and like considerations furnish an indica- 
tion for the prophylactic treatment of hysteria. It is 
very evident that hysterical environment must be 
avoided, and this is doubly true when in addition 
there is a distinctly neurotic taint. Unfortunately, 
the physician is, in the vast majority of cases, utterly 
unable to carry out this prophylaxis. He may per- 
form the disagreeable duty of advising that the 



TREATMENT. 223 

children be kept as much as possible out of the 
society of the hysterical mother, but generally such 
advice is worse than futile. 

Much may be accomplished in the way of prophy- 
laxis by the judicious education of body and mind. 
Children with a neurotic taint should be taken in 
hand early, and great care should be exercised as to 
their physical development. The love of outdoor 
life should be strenuously inculcated, and every in- 
ducement to outdoor exercise offered. A love for 
nature, or fondness for some outdoor sport, has 
saved many a child that was almost predestined to 
hysteria. A great deal depends upon the systematic 
training of this class of children. Their education 
should be in competent hands, and it should be 
supervised by some one conversant with the child's 
disposition. The school hours should not be long, 
but the child should be kept occupied while in school. 
Contests for prizes should, so far as possible, be 
discouraged. As the child grows older, the reading 
should be carefully directed, and sensational litera- 
ture forbidden. There is much truth, even if there 
is a little exaggeration, in what Tissot says : " If 
your daughter reads novels at fifteen she will have 
hysteria at twenty." The development of the sexual 
life is a period especially to be watched, and children 
should unquestionably have these matters explained to 
them as soon as they are old enough to understand. 
The morbid curiosity surrounding this physiological 
question should be early replaced by a clear under- 
standing of the principles of reproduction. It should 



224 HYSTERIA : ITS NATURE AND TREATMENT. 

be the great effort of those directing the education of 
the class of children of which we have been speak- 
ing, to avoid all emotionalism and sentimentalism ; 
to inculcate healthy views of life ; to suppress the 
tendency to excess in matters social or religious ; 
and to implant the principles of sound morality. 
Space does not permit any further elaboration of 
the details of this prophylactic treatment. Its im- 
portance cannot be exaggerated, since if it be suc- 
cessfully carried out the life of the individual is 
unspeakably benefited. The vigorous outdoor life 
of the English has developed a race in which there 
is very little hysteria, while the more artificial, ex- 
citable life on the Continent has had the opposite 
effect. 

The treatment of hysteria falls naturally under 
two heads : first, the treatment of the general hys- 
terical state, and second, the treatment of certain 
special symptoms. It should be stated, at the very 
outset, that a sine qua non of the successful treat- 
ment of hysteria is the treatment of each individual 
case. Few general rules can be laid down, or if 
such rules are dogmatically stated, the exceptions 
are very numerous. The physician must first calcu- 
late the personal equation of the patient. The edu- 
cation, mode of life, family history, tastes, disposi- 
tion, special likes and dislikes, must all be noted. 
Unless the physician gains, to some degree at least, 
the confidence of the patient, commands her respect, 
comes to possess a certain influence over her, and 
convinces her that he understands her particular 



TREATMENT. 225 

case, no treatment will avail. Again, it should be 
clearly understood that the physician's authority is 
absolute. I have seen many failures in the treat- 
ment of hysteria, due to the fact that above the 
doctor stood a father or mother as the high court of 
appeal. It is always well to have the matter form- 
ally settled before undertaking the case. One great 
reason why the treatment of hysteria is so much 
more successful in institutions than at home is, 
because in a hospital or sanatorium absolute obedi- 
ence to the rules is insisted upon. 

The daily life of the patient should be arranged 
for her; for example, it is well to write out a sched- 
ule upon which is set down the hour of rising, the 
time and character of the meals, the periods for rest 
and exercise, and like details. The establishment 
of regular habits, that are carried out with martial 
exactness, is the first step in the treatment. It is 
well to inquire minutely into the daily routine of the 
patient's life, and impress her with the importance of 
the various measures instituted. 

The hysterical subject has, as a rule, an excellent 
memory about everything that closely concerns her- 
self, and she is disappointed if the physician does 
not seem to keep the run of her particular case. 
The treatment is both direct and indirect ; direct in 
that it aims to remove the cause and thus cure the 
disease, and indirect in that it attempts to relieve 
certain symptoms that complicate the disease, though 
they do not in any sense form a part of it. The 
central idea in the treatment of hysteria may be ex- 



226 HYSTERIA: ITS NATURE AND TREATMENT. 

pressed by the word " suggestion." Again and 
again in the preceding chapters has it been shown 
that hysteria and hypnotism are related, and this re- 
lationship indicates the line of treatment. The men- 
tal condition of the hysterical subject is a reflex of 
that of the hypnotized subject, and suggestion finds 
a ready acceptance. We have to do with a mental, 
not a bodily, disease, and according to the views ad- 
vanced in chapter n, the part of the brain involved 
is that in which are situated the higher centers. The 
treatment, then, must be mental, — we must veritably 
" minister to a mind diseased." Therefore, the 
ordering of the patient's life — the directing the man- 
ner in which the day must be spent — makes a strong 
suggestion, first, of the authority of the physician, 
and second, of the importance of the disease. A 
mistake that is too apt to be made is to consider 
hysteria too lightly, to insist to the patient that it is 
trivial — a mere nothing. The patient knows only 
too well that there is something the matter, some- 
thing beyond her control, and is irritated by being 
told that she must exercise more will-power. All 
treatment, whether it be drug or hygienic measure, 
should be made impressive — should be tipped, as it 
were, with suggestion. The regulation of the diet 
is a very important thing, and it is not sufficient to 
simply tell the patient to eat more. As a rule, hys- 
terical patients eat irregularly, spasmodically, now 
too much, now too little, and their taste is apt to be 
perverted In the milder cases, all that is necessary 
is to see that the three meals are ample. Meat 



TREATMENT. 227 

should form an important part of the dietary, with 
eggs, milk, and simple vegetables. Sweets are to 
be avoided, and the dessert should consist of fruit. 
It is best to interdict alcohol, except in particular in- 
stances, and then the malt liquors are preferable to 
spirit or wine. In more severe cases it becomes 
necessary to give nourishment more frequently, and 
in all cases, even the milder ones that have just been 
considered, it is often well to have the patient take 
something light, — a glass of milk and a slice of 
bread and butter, — between meals and before bed- 
time. The details of the diet and the mode of ad- 
ministering food in the severe cases will be described 
under The Rest Cure, in another chapter. 

After having properly regulated the diet and in- 
creased the amount of nutritious food in the manner 
suggested, the next thing is to strike the balance 
between rest and exercise, and this is often a diffi- 
cult matter to arrange. Here the individual equation 
comes in, and must determine, to a great extent, 
how far exercise should be pushed. In some cases 
exercise seems at first to aggravate the symptoms, 
especially the pain, and hence must be taken very 
gradually. There can be no question as to the great 
benefit to be derived from proper exercise. Syden- 
ham recognized the value of exercise in the treatment 
of hysteria, and strongly recommended horseback 
riding. The great difficulty is to get the patient 
interested in some outdoor exercise, for without 
interest it becomes drudgery, and " there is no profit 
where no pleasure's taken." Here the ingenuity of 



228 HYSTERIA: ITS NATURE AND TREATMENT. 

the physician is often sorely taxed, for the hysterical 
subject has to be pushed along. Walking should be 
prescribed in. definite quantity; as, for example, in- 
struct the patient to take a brisk walk of half an 
hour, morning and afternoon, or twice or thrice that 
much if necessary. I have adopted a plan that 
works well. I am accustomed to say to my pa- 
tients, where, of course, I know the distances, walk 
to such and such a place and back. Or I direct 
them to ride to a certain point and walk back. 
I have found that they are much more willing to 
do this than simply go out on their own account. 
Horseback riding is excellent, and patients are apt 
to become fond of it. The bicycle has come as a 
boon to the victims of hysteria, and doubtless has 
more cures justly attributed to it than any other 
remedy of recent times. Its excellence consists in 
the fact that it is a form of exercise that can be 
easily regulated, is within the. reach of all, gives 
a maximum amount of fresh air with a minimum 
amount of exertion, is interesting in itself, and in 
the treatment of hysteria has the special advantage 
of occupying both mind and muscles. 

Gymnasium exercise is to be recommended only 
in cases where outdoor exercise is not possible. 
Passive exercise is of very great benefit in the 
severer cases, and will be specially considered in 
another chapter. As a rule, it is not necessary to 
employ massage when the patient can be induced 
to take sufficient outdoor exercise, though in certain 



TREATMENT. 229 

instances, particularly where there is contracture or 
paralysis, it is very useful. 

It is generally advisable to have a place in the 
schedule for rest, half an hour before luncheon and 
aeain half an hour before dinner. It is of extreme 
importance that hysterical patients have long hours 
in bed. Such patients are very often better at night 
than through the day, and will insist upon sitting up 
late. It is a good plan to require from nine to 
twelve hours in bed, whether the patient can sleep 
or not. It should be made plain to them that the 
simple rest in bed is beneficial, and often they can 
be educated to accustom themselves to this. 

A question that is hard to settle, and one that 
must be determined in each individual case, is the 
occupation of the .patient. In many, if not most, of 
the mild cases, it is far better to permit light work — 
household duties, and the like — provided they are not 
burdensome or distasteful. In some cases there is a 
feverish anxiety to be doing something that has to 
be restrained. 

The old writers on hysteria laid great stress on 
the influence of the sexual life on the course of the 
disease. This view was a perfectly consistent one 
at a time when the uterus was supposed to be the 
fons et origo of the disease. It was claimed, how- 
ever, long after . the decay of this theory, that a 
life of continence was very productive of hysteria. 
According to Briquet, the older writers " shuddered 
with one accord over the lot of the poor widows 
who, according to their notions, were the inevitable 



230 HYSTERIA: ITS NATURE AND TREATMENT. 

victims of hysteria." As has been said in a previous 
chapter, this view is entirely erroneous. The hys- 
terical subject is not erotic, — in fact it has been pretty 
clearly shown that the sexual instinct is rather sub- 
normal. The hysterical woman desires to attract 
the attention of men, but the sexual act itself is 
often repugnant to her. Kraft-Ebing * says that in 
the hysterical the sexual instinct is often abnormally 
great, though in another part of the book he calls 
attention to the fact that absence of sexual feeling is 
especially to be found among hysterical individuals. 
The dictum of Hippocrates, quoted above, " nub at 
ilia et morbum effugiet" is true, but in an entirely 
different sense from that in which he intended it. 
Provided the hysterical subject marries happily, her 
life becomes filled with new objects. It has wider 
purposes ; it absorbs her energies ; it takes her out 
of herself; it develops and strengthens her charac- 
ter ; it is the fulfilment of her mission in the world. 
On the other hand, if her married life be not a happy 
one, the disease is always aggravated, and this is 
especially so when the union is unfruitful. Some of 
the most intractable cases of hysteria that have ever 
come under my notice have been in childless women. 
Clearly, then, the " besom genitaux" has little or no 
place in the etiology of hysteria. Masturbation and 
sexual perversion, however, would seem, in my 
experience at least, to be rather more common in 
hysterical subjects than in those free from the dis- 

*" Psychopathia Sexualis." 



TREATMENT. 231 

ease. In these cases it is probable that the heredi- 
tary degeneracy which has predisposed to hysteria 
has brought in its train certain sexual abnormalities. 

The social relations of the hysterical subject must 
be determined in each individual case. In bad cases 
it is necessary to resort to isolation, and in general, 
as has been said, such patients do best away from 
home. Of course, the ideal treatment of the aver- 
age case of mild hysteria is travel. In this is com- 
bined a certain amount of outdoor exercise, an 
entire change of scene, a removal from the sur- 
roundings that have perhaps contributed to the pro- 
duction of the disease, and at the same time there 
is excited an interest in new things and strange 
people which relieves the self-concentration. Unfor- 
tunately, this plan of treatment is of very limited 
application, especially in this country, where the 
distances are so great and the change of scene not 
so abrupt as it is on the continent of Europe. The 
"wilderness cure" of Weir Mitchell is often produc- 
tive of excellent results. This is not very expensive, 
requiring merely a tent and outfit, with a few com- 
panions, and there are a great many places within 
easy reach where a small party can spend a summer 
in a most agreeable fashion. This plan is especially 
to be recommended for the treatment of hysteria in 
men. 

From what has been said about the general man- 
agement of hysteria, it will be seen that the treat- 
ment in the main aims at the mental symptoms. 
The regular routine, the multitude of little things to 



232 HYSTERIA: ITS NATURE AND TREATMENT. 

be done, the various commands to be obeyed, all 
these things tend to gradually restore and build up 
a weakened will-power. It is suggestive in the ex- 
treme ; it says to the patient : " You must do this 
or that " ; " These things that are being done, so 
many and varied, are surely going to be beneficial." 
In the more severe cases, to which the vigorous rest 
cure is applied, the suggestion becomes much more 
imperative — the darkened room, the strange faces, 
the absolute isolation from home and friends, the 
many details of treatment, all make a powerful im- 
pression upon the hysterical mind. Again, the 
treatment is mental, in that it surrounds the patient, 
as far as possible, with new objects. It is impossible 
to banish a disagreeable thought by a mere fiat of 
the will, but the thing that is possible is to put an 
agreeable thought in its place. Hence the exercise, 
pleasant occupation, and the like. The treatment 
of hysteria by hypnotic suggestion has never real- 
ized the expectations that the early attempts in this 
direction promised. Still, much may be done in 
this direction, and the study of hypnotism has taught 
us much in the line of suggestive treatment. This 
subject will be further discussed in the section on 
Hypnotism. 

Running through the whole treatment of a case 
of hysteria must be a general moral effect exerted 
by the physician. This should not consist so much 
of a general exhortation to exert a weakened will- 
power, but should point out the general cause of 
the disease, if such cause is apparent, its course, the 



TREATMENT. 233 

mental elements entering into the case, and the pur- 
pose of the treatment. The patient knows only too 
well that her will-power is enfeebled and cannot be 
made to respond to the demands made upon it, and 
it should be the aim of the physician to make this 
clear ; to show her that the trouble lies in this 
weakened will-power ; and to impress upon her 
mind the fact that the treatment instituted is in- 
tended especially to invigorate this debilitated will. 
In this way it is possible to gradually work up to 
the point of stimulating the desire to recover, and 
the necessity of supreme exertion. The hysterical 
subjects need encouragement all the time, and they 
can be told, without fear of exaggeration, that they 
have a hard personal fight to make. Every positive 
symptom of improvement should be seized upon by 
the physician and made much of. The question is 
often asked, where the case is being treated at 
home, as to the extent to which sympathy should be 
expressed to the patient by members of the house- 
hold. The rule that ou^ht alwavs to be followed is 
to command the patient not to speak of her symp- 
toms to any one but the doctor, and to restrict the 
family in their inquiries as to the patient's condition. 
A strict insistence upon the observance of this pro- 
cedure will often save a vast amount of annoyance, 
and be of distinct benefit to the patient. 

In addition to these general measures, there are 
certain more special therapeutic agents that have been 
found useful in the treatment of hysteria. Of these, 
the one that occupies easily the first place is hydro- 



234 HYSTERIA: ITS NATURE AND TREATMENT. 

therapy. No other single agent has been as useful 
in my hands as this. It is a good routine practice 
to order the cold douche to the spine, or the alter- 
nate warm and cold douche every morning. The 
subject is such an important one, and the therapeutic 
application of water has received so little attention 
in this country, that it seemed well to devote a spe- 
cial section to this subject. The same remarks 
apply in great measure to the application of electric- 
ity, which will also be considered more in detail. 
Of the different currents, perhaps the static is the 
most useful in the treatment of hysteria, though 
both galvanic and faradic yield good results. The 
utility of this agent is due in large part to its sug- 
gestiveness, and the same may be said concerning 
metallotherapy, which at one time was largely used 
in the treatment of certain of the accidents of hys- 
teria. 

From what has been said concerning the nature 
of hysteria, it is very evident that little can be ex- 
pected from the action of drugs. There is this very 
important fact to be borne in mind, however, that 
drugs form an excellent basis and opportunity for 
carrying out a general suggestive treatment. The 
mind of man has for so many ages attached a vast deal 
of importance to the use of medicines, and for this 
reason we cannot afford to neglect this avenue to 
the imagination. Hence in employing drugs in 
hysteria they should be used with a view to the 
mental impression produced, more than for their 
absolute physiological action. The quacks of all 



TREATMENT. 235 

ages have been quick to recognize this, and it is 
unfortunate that they have exploited it to such a 
disgusting degree, since it has, in a measure, deprived 
the profession of a very useful aid — the imagination 
of the patient. It should not be thought beneath 
the dignity of the profession to utilize this means, 
and in prescribing medicine for the hysterical patient 
as strong a mental impression as possible should be 
made. The physician should bear in mind the fact 
that in hysteria he is endeavoring to treat the mental 
and not the bodily condition, and should dwell upon 
the power of the particular drug in calming the 
nervous excitement, and the patient should be im- 
pressed with the fact that the symptoms complained 
of will be relieved. The effect may be heightened 
by administering the medicine frequently and in 
some particular manner. It is simply astonishing 
how much can often be accomplished by careful 
attention to these seemingly trivial and unimportant 
details. Just as in the hypnotic state a teaspoonful 
of water impregnated with suggestion will produce 
emesis or intoxication, so in hysteria the suggestion 
that is added to the medicine is the most important 
ingredient. It is a significant fact, and strongly 
confirmatory of the statement just made, that the 
various drugs that have been, from time immemorial, 
employed in the treatment of hysteria have all some 
very striking and peculiar odor. For example, asa- 
fetida, musk, valerian, sumbul, and so on. It is 
more than probable that the effectiveness of these 
remedies is in large part due to the pervading odor. 



236 HYSTERIA: ITS NATURE AND TREATMENT. 

Little need be said concerning the physiological 
action of these drugs, since it is too uncertain and 
feeble to require any special notice. Musk was 
freely prescribed by the older writers, but it is very 
rarely used at the present day. The dose is from 
5 to 15 grains in mucilage. Asafetida is perhaps 
the member of the group that has attained the high- 
est reputation in the treatment of hysteria, and is 
very largely prescribed, especially by the laity. The 
most convenient method of administering it is the 
officinal pill (three grains), of which two to four may 
be given at a dose. The other preparations of 
asafetida are rarely used in hysteria. (Mistura asa- 
fcetida, dose, gj ; and the tincture, dose 5j). With 
the profession, valerian has of late years largely 
taken the place of asafetida. Perhaps the best pre 
paration is the ammoniated tincture, dose 5j to 3iij, 
and the fluid extract, dose 5j. A preparation that 
has proved useful in my hands, and which has a high 
suggestive value, is valerianate of ether, put up in 
capsules. The patient shortly after swallowing one 
or two of these becomes distinctly aware of having 
taken medicine. Sumbul is another remedy of value, 
given in the form of the tincture, dose 5j to 5iv, or in 
pills of the solid extract. Camphor, monobromid 
of camphor, hops, lactucarium, and many other 
similar drugs have been prescribed, but are not as 
useful as the valerianates and asafetida. Of course, 
these various remedies have a slight sedative action, 
but it is so slight as to be unimportant in any other 
condition than hysteria. The bromids are very 



TREATMENT. 237 

largely prescribed in hysteria, but their use is very 
disappointing. Undoubtedly they have some effect 
in quieting " nervousness," but in well-developed 
hysteria they are of very little service. Of the vari- 
ous preparations of bromid the bromid of ammonia 
is the best to employ in hysteria. I have had some 
success with moderate doses of sulphonal, 10 to 15 
grains, three times daily. A distinct effect follows 
the administration of this drug, and very often the 
good result of administering sulphonal in such doses 
is very apparent. Of course, it should not be pushed 
to the point of producing somnolence. There are 
three other druofs that are orven far too often in 
hysteria: opium, chloral, and alcohol. The hysteri- 
cal subject too frequently becomes addicted to the 
use of one or other of these substances. It may be 
taken as a safe general rule that no one of these 
three remedies should ever be resorted to in pure 
hysteria. Of course, there may be exceptions, but 
these should be very few. Many other drugs might 
be included in this category, but the principal ones 
have been mentioned. Little need be said concern- 
ing- the use of tonics, digestives, and the like. Iron 
is often indicated, and when indicated should be 
given freely in the form of Blaud's pills, Glide's 
pepto-mangan, or the tincture of the chlorid. 
When forced feeding is being employed, it is often 
necessary to aid digestion by some of the pepsin 
compounds. 

While the plan of treatment laid down above ap- 
plies to the general management of the disease, it 



238 HYSTERIA: ITS NATURE AND TREATMENT. 

might be well to call attention briefly to the treat- 
ment of certain special symptoms. 

The utility of suggestion in the treatment of 
hysteria becomes most apparent when applied to 
certain special symptoms, for here the suggestion 
assumes a concrete form. 

Anesthesia and Hyperesthesia. — In the treat- 
ment of anesthesia, whatever be the variety, elec- 
tricity is the most valuable agent that can be em- 
ployed. While the static is, perhaps, the best form 
of current to use, — on account, I believe, of its 
greater suggestive value, — the other currents can be 
made almost equally useful. A very good method, 
and one within reach of the general practitioner, is 
the use of the faradic current with the wire brush 
electrode. One electrode, covered with sponge or 
cotton, is held at some indifferent point, and the 
brush is slowly passed over the anesthetic area. It 
is well to gradually increase the strength of the 
current. The sittings should be short, — from five to 
ten minutes, — and daily. Friction of the skin with a 
hair glove or other rough substance will often be 
found beneficial, as will the use of the cold douche, 
— a fine spray driven with force directed upon the 
anesthetic region. On the Continent, apparently 
some success has been attained by the application 
of certain metals to the insensitive surfaces. The 
subject of metallotherapy, as this procedure is 
termed, will be discussed elsewhere. 

It is quite possible that the value of the electric 
current is something more than merely suggestive, 



TREATMENT. 239 

since the vigorous stimulation of the peripheral 
nerves may exert a directly beneficial action. Much 
the same plan of treatment is to be followed in the 
case of hyperesthesia and hysterical pains in gen- 
eral, except that here the continuous galvanic cur- 
rent seems to be more serviceable. Special sense 
disturbances — amblyopia, deafness, involvement of 
taste and smell — are to be treated with specialized 
electrodes described in another section. In the case 
of hysterical deafness, the patient should be made to 
listen every day for a specified time to the ticking 
of a watch or clock. Hysterical loss of voice is 
very amenable to treatment by the faradic current. 
One electrode is placed at some indifferent point 
and the patient is held by assistants so that she 
cannot run away, and the other electrode is either 
introduced into the upper part of the larynx, or, 
what in my hands has answered equally well, held 
over the outside of the larynx. If this latter 
method is pursued, after the electrodes are in place 
a strong current is suddenly turned on, and in 
nearly every case the patient will make some ex- 
clamation. Usually, in hysterical mutism, after some 
sound has been uttered, the patient can be encour- 
aged to attempt to use the voice. 

Paralysis. — Here, again, faradization or static 
electricity produces excellent results. These cases 
require close attention, and the physician should 
carefully examine' the paralyzed parts every day, 
making some test, with the dynamometer, for exam- 
ple, as to the gain in strength. It should be borne in 



2 4 o HYSTERIA: ITS NATURE AND TREATMENT. 

mind that in using the dynamometer with hysterical 
patients it should be so arranged that they are not 
able to see the index. In a case recently under my 
care, the following method was employed : The 
patient, a young girl, had complete paralysis of the 
right leg, not being able to move the limb even in 
bed. The first seance consisted in making her move 
the toes alone. As soon as this was accomplished 
the day's treatment was over. The next day the 
foot was moved, first passively and then she was 
made to move it herself. Then a task would be 
set ; for example, she would be told that she was to 
practise for one day outward rotation of the leg. 
She was shown how to make the movements, and all 
other motion of the le£ was forbidden. Later, the 
foot was put to the floor, then some weight was borne 
on it ; next, walking with the assistance of two per- 
sons, until the patient was gradually taught to walk 
alone. The treatment extended over several weeks, 
but this particular case was a difficult one and of 
some months' standing. This case is described 
somewhat at length to illustrate the method of pro- 
cedure. In addition to these daily exercises faradi- 
zation should be practised, together with massage 
and Swedish movements. 

Hysterical contractures are often very intractable, 
and frequently last for months or even years in spite 
of the most careful treatment. The faradic current, 
so useful in paralysis, does harm rather than good 
in contracture, and the galvanic current should be 
employed in preference, though even this very fre- 



TREATMENT. 241 

quently fails to accomplish anything. Massage, in 
like manner, is of little avail. There is no advantage 
in attempting forcibly to straighten the limb that is 
the seat of the contracture. Sometimes, by long- 
continued gentle manipulation, the contracture can 
be overcome. Perhaps the best way to deal with 
these cases is to put the patient under chloroform, 
reduce the contracture, and then place the limb upon 
a splint so that the contracture cannot return. This 
procedure has the advantage of allowing the physi- 
cian to examine the joint carefully and thus to decide 
upon the nature of the contracture, if it had not 
previously been clearly made out. It is astonishing, 
however, to see how quickly a contracture will re- 
turn after having been for weeks held straight on a 
splint. Counterirritants and the actual cautery — a 
very favorite mode of treatment — are of compara- 
tively little value in genuine hysterical contracture. 
The cases that are cured by these means alone are 
usually those in which there is an element of malin- 
gering. In rare instances, perhaps, surgical inter- 
ference becomes necessary, but it is only in those 
unusual cases in which, after complete relaxation of 
the muscles has been obtained through the adminis- 
tration of an anesthetic, it is seen that there is actual 
shortening of the tendons. Attention has already 
been called to the fact that hysterical contracture 
may exist for years without any change taking place 
in the joint, though, as Charcot has shown, this may 
happen. 

Convulsive Seizures. — The treatment of the 
21 



242 HYSTERIA: ITS NATURE AND TREATMENT. 

grand attack of hysteria, and the many modifications 
of it which have been spoken of, is often a very 
troublesome matter. In private practice, the alarm- 
ing- appearance of the patient spreads terror and 
confusion through the household, and no amount of 
assurance on the part of the physician can convince 
the friends and relatives that the condition is not 
fraught with great peril. Then, too, the measures 
employed will often provoke adverse criticism. I 
remember, on one occasion, what abuse was heaped 
upon me for hypnotizing a girl who was in the latter 
stage of the grand attack. I was accused of trifling 
with a case of very serious illness. In the City 
Hospital, where we see many cases of paroxysmal 
hysteria, there are certain routine measures em- 
ployed, some of which, while perhaps rather vigor- 
ous, are nevertheless effective. The first procedure 
is to attempt to cut short the attack by pressure 
upon the hysterogenic zones, and if this fails, an ice 
suppository will often stop the milder attacks. If 
this fails, t l of a grain of apomorphia is given hypo- 
dermically, which in a short time produces emesis 
and with it an end of the attack. For the worst 
cases chloroform is resorted to. I have several 
times succeeded in hypnotizing patients in this stage 
and stopping the attack by suggestion. It is evident 
that in private practice certain of these measures 
cannot be employed. The first thing to be done, 
as Gilles de la Tourette has insisted upon, is to 
secure absolute quiet for the patient. It is best to 
have a mattress put on the floor, so as to avoid the 



TREATMENT. 243 

danger of the patient hurting herself in the violence 
of the grand movements. Sometimes it is neces- 
sary to employ a sheet tied over the bed, or some 
improvised camisole. This is better than attempt- 
ing to hold the patient. Ovarian compression should 
be at once resorted to and in a considerable per cent, 
of cases this will cut short the attack, or at least 
bring on a period of calm. The custom of putting 
on an ovarian compress, so much in vogue at the 
Salpetriere, is rarely employed in this country. The 
shock of cold water dashed in the face, or a few 
whiffs of nitrate of amyl or chloroform, will often 
have a happy effect. If these measures fail, the 
chloroform should be pushed to narcosis, or emesis 
induced by apomorphia. It is well to try hypnotism 
in all cases, and when the state of lethargy is pro- 
duced suggestion may be made, and the patient told 
that she will be well when awakened, or, what is 
perhaps better, she may be permitted to sleep for 
several hours. By adopting this latter method, the 
state of delirium, which is often troublesome, is 
averted. Careful attention to the patient is neces- 
sary at the close of the convulsive attack, for then it 
is that certain accidents, such as paralysis or con- 
tracture, are apt to make their appearance. Much 
can be done by suggestion, even when it is not 
possible to produce hypnotic lethargy. I have fre- 
quently observed patients at or near the close of a 
convulsive attack, in whom suggestion was nearly as 
potent as it is in the hypnotic state, and the physi- 
cian should always look out for this condition and 
take advantage of it. 



244 HYSTERIA : ITS NATURE AND TREATMENT. 

It will be seen that in the management of the 
general and special symptoms of hysteria, a great 
deal depends upon the ingenuity of the physician. 
As has been said above, he should assume the en- 
tire control of the patient, and by a firm manner and 
careful attention to the minutest details, can accomp- 
lish much. It is a mistaken idea that hysterical 
subjects can be frightened out of an attack by noise 
and bluster, and threats of the hot iron. This 
method will often succeed with malingerers and 
pseudohysterics, but not in genuine hysteria. 

In the foregoing pages, frequent reference has 
been made to certain special procedures which are 
employed in the treatment of hysteria. These 
measures are of such importance that they must 
now be considered more in detail. 



CHAPTER X. 

ELECTROTHERAPY.— HYDROTHERAPY.— 
MASSAGE. 

We are still very far from a perfect understanding 
of the effects of electricity upon the human body. 
We know that nerve and muscle can be stimulated 
by the electric current, but in what way this effect is 
brought about is still obscure. Again, there can be 
no doubt of the fact that in many cases the electric 
current will relieve pain, but it is not definitely 
known how this is accomplished. It may be due to 
the stimulation of the peripheral nerves, and in an 
indirect way, perhaps, a stimulation of the centers, 
or, as has been suggested, the application of the 
electric current to the surface of the body may 
hasten or retard certain electrobiological changes in 
the deeper structures. In making use of electricity 
in the treatment of hysteria, it is not claimed that 
this agent produces any distinct physiological effects, 
or at least anything beyond the stimulation of the 
skin and peripheral nerves, and the muscles. In- 
directly the stimulation of large areas of the skin 
produces certain distinct changes in the superficial 
circulation, and in this way may influence the circu- 
lation as a whole. Again, as has just been said, 
vigorous stimulation of the peripheral nerves will un- 
doubtedly be felt in the nerve centers ; and perhaps 

2 45 



dl 



246 HYSTERIA: ITS NATURE AND TREATMENT. 

this factor has been overlooked in applying electric- 
ity to the treatment of hysteria. On the other hand, 
if we consider the nature of hysteria, looking upon 
it as an involvement of the higher brain centers, and 
then consider that electricity has for so long been 
invested, by the laity at least, with mysterious pow- 
ers in the treatment of disease, we see in this agent 
the thing par excellence with which to produce a pro- 
found mental impression. While, as was stated 
above, electricity may produce certain definite effects 
upon the nervous system, there can be no doubt of 
the fact that its great usefulness in the treatment of 
hysteria depends upon the mental impression it 
produces. 

Electricity may be employed both in the general 
treatment of the hysterical condition and also for the 
treatment of certain special symptoms. In the gen- 
eral treatment of the hysterical condition any of the 
currents may be employed for the purpose of either 
stimulating the cutaneous surface or the muscles. 
A very good plan of administering the current for 
these purposes is to have a large foot-plate covered 
with a damp cloth, and make the patient place the 
feet upon this while the cutaneous surface may be 
gone over with a wire brush. In the same manner, if 
it is desired to stimulate the muscles, a small sponge- 
covered electrode should be used instead of the 
brush. Almost any kind of faradic apparatus will do 
for this treatment. In the same way, general stimu- 
lation may be very easily accomplished by the static 
current. It may be said in regard to this form of 



ELECTROTHERAPY. 247 

electricity that it possesses, to a much higher degree 
than do the other varieties, suggestive properties, 
and consequently it has come to be employed very 
largely in the treatment of hysteria. The galvanic 
current may be employed in the general treatment 
of hysteria, either by going over the skin and mus- 
cles in much the manner described above, or by 
limiting its application to the region of the spine. 
Mild currents (five to ten Ma.) passed through the 
head are sometimes distinctly beneficial in the treat- 
ment of hysterical head pains. In treating hysterical 
paralysis the affected muscles should be made to con- 
tract vigorously, and for this purpose the faradic 
current is the best. As has been said, electricity 
does not seem to be of much benefit in the treat- 
ment of contracture. Anesthesia is best treated by 
the faradic current and the wire-brush electrode. 
The continuous, or interrupted galvanic current, is 
also useful. This current is to be preferred in the 
treatment of painful affections. Prince * has ob- 
served that it not infrequently happens that cases of 
what seem to be hysterical neuralgias are, in reality, 
instances of localized neuritis, complicating the hys- 
teria. In such cases the galvanic current is of far 
greater value than either of the other forms of elec- 
tricity. The faradic current has been used to cut 
short the convulsive attack, and the galvanic current 
may be employed for the same purpose. One elec- 
trode should be placed over the most distinct hystero- 

* ' ' Jnternat. Syst. of Electrotherap. ' ' 



248 HYSTERIA : ITS NATURE AND TREATMENT. 

genie zone, and a strong- current used. In two cases 
of hysterical lethargy I found this method eminently 
satisfactory. It is not necessary to describe in detail 
the many symptoms of hysteria that are often suc- 
cessfully treated by electricity, nor the special modes 
of applying the various currents. Enough has been 
said to show that suggestion plays the most import- 
ant role, and hence every effort should be made to 
intensify this suggestive element, both in the appa- 
ratus used and in the manner of its application. 

The history of the use of the magnet in the treat- 
ment of disease, especially hysteria, is extremely 
interesting. It would seem that from very early 
times the magnet had been employed as a thera- 
peutic agent, and certain distinct effects were attrib- 
uted to its use. Aetius employed it in convulsions, 
and Paracelsus to prevent epilepsy. Gilbert (1600), 
Etmuller, and most of the early writers, advocated 
the use of the magnet in many nervous disorders. 
Laennec * states that he obtained good results in 
cases of spasms by applying the magnet to the skin. 
For a long time the use of the magnet in medicine 
was discontinued, when a few years ago it was re- 
vived in France. Charcot")- employed it in the treat- 
ment of hysterical contractures and anesthesia. 
Axenfeld and Huchard,J in their "Traite des Nev- 
roses," published in 1883, say as to the physiological 
effects of the magnet, that it produces a feeling of 
intoxication and vertigo, and that the various secre- 

* " Traite de L'Auscult." -f- Op. cit. % Op. cit. 



ELECTROTHERAPY. 249 

tions are modified. They describe the peculiar 
phenomenon of "transfer," which consists in placing 
a horse-shoe magnet in contact with, or even near, 
the affected part. The result, as these authors de- 
scribed it, was that the contracture or paralysis would 
gradually pass to the opposite side. The magnet 
was then moved to the side to which the disease had 
gone, and soon the paralysis, contracture, or anes- 
thesia would reappear in its former site. This proce- 
dure, several times repeated, finally brought about a 
cure. These writers consider the magnet very useful 
in the treatment of many hysterical stigmata. Cita- 
tions could be given down to a very recent date 
from well-known writers, — as, for example, Richer,* 
— gravely describing the remarkable effects produced 
by the magnet. Less than ten years ago I saw the 
magnet frequently used in the Paris hospitals. Con- 
trast the citations that have been given with the fol- 
lowing statement from two well-known electricians, 
Edwin J. Houston and A. E. Kennelly : f " So far as 
we know at the present time, it would appear that the 
magnetic flux is absolutely without influence either 
upon the human body or on any of its physiological 
processes ; and that, consequently, if any therapeutic 
effects -do attend the use of magnets, the cause 
must be of a psychic rather than of a physiological 
nature. .... When, for example, a person is 
placed with his head between the poles of a powerful 



*" Paralysies et Contractures Hysteriques,'" 1892. 
f " Electricity in Electrotherapeutics." 



.-* 



250 HYSTERIA: ITS NATURE AND TREATMENT. 

dynamo-electric machine from which the armature 
has been removed, so that the flux passes directly 
through the head, even prolonged exposure has 
failed to produce any observed effects either on the 
pulse or respiration, whether the magnetic flux was 
intermittent or was steadily maintained. Or take the 
case of a powerful electromagnet, made by wrap- 
ping an iron cannon with a suitable magnetizing 
coil, and producing a flux sufficiently great to cause 
heavy iron bars or bolts to be sustained on the 
person of a soldier standing before the gun. Under 
these circumstances no sensations were experienced 
by the soldier, other than those of pressure from the 
attracted masses of iron." 

The history of the employment of the magnet in 
the treatment of hysteria is an excellent object-les- 
son. Here is an agent employed and esteemed by 
both ancient and modern physicians in the treat- 
ment of this disease, and when the crucial test of 
exact scientific experimentation is applied to it, it is 
shown to have absolutely no action upon the human 
body. It is going too far to say that although it has 
no action on the healthy body it exerts some physio- 
logical action on the hysterical subject. That it 
does produce certain effects on hysterical subjects 
we cannot doubt from the multitude of recorded 
cases, but this action is purely psychic. There can 
be no objection whatever to its use in the treatment 
of hysteria, but the physician employing it should 
recognize that its action is upon the mind and not 
the body. 



ELECTROTHERAPY. 251 

In the same category belongs the curious pro- 
cedure known as metallotherapy, which was reduced 
to a system by Burcq. Like the application of the 
magnet, this was simply a revival of a very ancient 
practice. Mention of the external application of 
metals for the treatment of various diseases may be 
found in the writings of Galen, Paracelsus, van 
Helmont, and many of the old authors. The obser- 
vations of Burcq * — published in 1853, and confirmed 
by many eminent physicians, in France especially, — 
were, in brief, that hysterical subjects had special 
affinities for certain metals, and that these metals 
produced certain marked results on anesthesia, par- 
alysis, contracture, and other hysterical stigmata. 
The method of application was to take discs of 
various metals — gold, silver, copper, zinc, etc. — of 
the size of a large coin, and apply one or more 
of them to the affected parts by means of a band- 
age. In from fifteen to twenty minutes certain 
effects began to be observed ; if the metal had been 
applied to an anesthetic area, a zone of normal 
sensibility would make its appearance, and would 
gradually extend until the whole of the anesthesia 
had disappeared. After a certain time the anes- 
thesia would return. There was noted also the 
phenomenon of transfer : the anesthesia leaving the 
part first affected and involving a corresponding part 
on the opposite side of the body. In the same man- 
ner, paralyses and contractures were cured by apply- 

* " Mettallotherapie. " 



252 HYSTERIA: ITS NATURE AND TREATMENT. 

ing metals to the surface of the skin, and the same 
treatment was used in hysterical involvement of the 
special senses. This idea was pushed still further, 
and what was called internal metallotherapy, — the 
administration of metals in solution, and also baths 
of the various solutions, — was largely resorted to in 
the treatment of hysteria. Afterward it was dis- 
covered that certain kinds of wood had a similar 
action, and this procedure was spoken of as xylo- 
therapy. The scientific explanation of metallo- 
therapy was discussed by various learned societies, 
and the theory that seems to have obtained the 
most support was that the metal-plate set up an 
electric current. It hardly seems credible, at this 
day, that only a few years ago such an absurdity 
should have received as much attention as did this 
one, from so many able men. The literature on the 
subject is enormous, and not confined to journal 
articles, but numbers many large volumes. Of 
course, the whole explanation of the good results 
that were certainly obtained by this mode of treat- 
ment is that it was merely a new and rather impres- 
sive mode of utilizing the principle of suggestion. 
The success which attended the use of the magnet 
and metallotherapy emphasizes most strongly the 
value of suggestion in the treatment of hysteria. 

Hydrotherapy. — The use of water as a thera- 
peutic agent dates back to the earliest authentic 
records. In the writings of Hippocrates may be 
seen specific directions concerning the diseases in 
which water was supposed to be beneficial, and the 



HYDROTHERAPY. 253 

mode in which it was to be employed. He directed 
attention, especially, to the use of cold water in 
fevers, and also showed that a brief application of 
cold water to the skin had a marked revulsive action. 
In the works of all the older writers water was given 
a distinct place among the various therapeutic agents, 
— Celsus, Araetius, Alexander of Tralles, Frederick 
Hoffman, and so on. The past decad has wit- 
nessed a remarkable revival of hydrotherapeutics, 
after a long period of disuse. This is especially 
true of this country, since upon the Continent of 
Europe water has always been used therapeutically. 
The very marked advantages obtained from the use 
of water in the treatment of fevers, especially ty- 
phoid, has emphasized its action, and it is to be 
hoped that before long it will be employed in many 
non-febrile affections, since the reduction of higfh 
temperature is only one of the many ways in which 
water may be used with advantage in the treatment 
of disease. In general, it may be said that the prin- 
ciple upon which hydrotherapy rests is the application 
of heat and cold to the body, and water is used as the 
vehicle, so to speak. In no other manner can heat 
or cold be so evenly applied to the surface of the 
body, or so exactly regulated. Again, by the appli- 
cation of water we are enabled to emphasize the 
contrast between heat and cold, and thus obtain a 
revulsive effect which is often useful. The general 
conclusions as to' the physiological action of water 
may be expressed as follows : (i) As to the circula- 
tion. There can be no doubt of the fact that by 



254 HYSTERIA : ITS NATURE AND TREATMENT. 

the use of water a greater activity can be imparted 
to the circulation. The oxygenation of the blood 
is markedly improved (Dujardin Beaumetz *) and 
the hematopoietic organs are stimulated. More than 
this, Thayer -f has shown that after the cold bath the 
number of leucocytes is greatly increased. (2) It 
would seem that by the use of water, especially its 
revulsive action, the functions of the brain and cord 
are stimulated. It is not certain just what the ex- 
planation of this action is ; most probably the stimu- 
lation of the central nervous system is brought about 
both by the stimulation of the peripheral nerves, 
and also by the change in the caliber of the super- 
ficial blood-vessels. This latter action is one of 
great value, for in this manner the circulation is 
equalized and congestion in internal organs relieved. 
(3) The action of water in depressing the tempera- 
ture has been so fully discussed of late that it need 
not be mentioned here. There can be no doubt, as 
Baruch J says, that heat and cold act as powerful 
reflexes to the central nervous system. 

Water being used mainly to apply the principle of 
heat and cold to the body, the first point to be ob- 
served in its application is the range of temperature. 
As Baruch § has said, there is a wide range in tem- 
perature, the extremes being, for cold 40 F. and for 
heat 1 io° F. Beni Barde || makes the rather conve- 
nient classification for practical use as follows : 



* Therap. Gazette, 1888. f Johns Hopkins Bullet., 1893. 

% Med. Rec. y 1893. \ Loc. cit. || " Hydrotherapies' 



HYDROTHERAPY. 255 

Water from 8° to 12 C. (46 to 53 F.), very cold. 

12 to 16 C. (53 to 6o° F,), cold. 

26 to 30 C. (78 to 86° F.), warm. 

" above 4o°C. (104 F.), hot. 

Following the same author, the effects of warmth 
applied by means of water are: (i) A tendency to 
slightly raise the temperature of the body. (2) An 
increase in the frequency of the respirations. (3) 
An acceleration of the circulation. (4) An increase 
in muscular irritability when the water is moderately 
warm. (5) A diminution of nervous irritability. 

Moderate cold applied to the body (1) decreases 
bodily temperature. (2) Decreases the frequency 
of respirations, which become deeper. (3) De- 
creases the frequency of the circulation. (4) Low- 
ers muscular contractility. (5) By its impression on 
the peripheral nerves it transmits a marked stimulus 
to the central nervous system. 

The general application of water to different dis- 
eases cannot here be considered, since we are con- 
cerned only with its use in the treatment of hysteria. 
It may be said that the two effects of water that are 
most valuable in the treatment of hysteria are : 
(1) The stimulation of the peripheral nerves, and a 
resulting stimulation of the central nervous system, 
and (2) the revulsive action. Of course, the two 
are closely related. The former action is utilized in 
the treatment of anesthesia and hyperesthesia. In 
the treatment of these conditions the water should 
be thrown from a spray, with a pressure of 15 
pounds or greater, and should have a temperature 



256 HYSTERIA: ITS NATURE AND TREATMENT. 

of from 50 to 6o° F. This spray should be passed 
rapidly over the whole body, except the head, and 
the seance should not last longer than half a minute 
to a minute. This douche can be improvised by 
attaching a rose spray to the faucet of the bath-tub. 
For the routine treatment of the hysterical condi- 
tion the alternate warm and cold douche is very 
beneficial. This can be carried out at home by using 
a piece of rubber-tubing attached to the bath-tub 
faucet, by pouring from a pitcher alternately warm 
and cold water, or by means of a large sponge. 
, The warm water should be first applied, the tem- 
perature being from 8o° to 85 F., followed imme- 
diately by the cold water of 50 to 6o° F. This 
alternate warm and cold douche is kept up for five 
minutes, the water being applied only to the spinal 
region. The patient then takes a vigorous rub with 
a coarse towel. In some cases it is better to use 
the douche or shower to the whole body, except the 
head. As a rule, the hysterical patient does not 
stand the cold plunge well, and the full warm bath 
is not to be recommended. 

The beneficial effects of hydrotherapy, both ex- 
ternal and internal, are seen to most advantage at 
special institutions, or at watering-places, where 
both the bath and the water taken internally are 
impregnated with some mineral. Of course, under 
these circumstances, it is hard to say how far the 
water alone is effective in bringing about the good 
results that are apt to follow a certain residence at 
some of these places. The change of scene, of 



MASSAGE. 257 

surroundings, of people, all contribute a very im- 
portant part in the cure. The use of the cold douche 
or of the cold pack is often of great service in cut- 
ting short the convulsive stage. Sea-bathing is, as 
a rule, very beneficial in hysteria. It is always nec- 
essary to caution the patient not to make too much 
exertion in the surf, and not to stay in the water 
more than fifteen or twenty minutes. 

In general, it may be said that in addition to the 
positive and demonstrable good effects obtained by 
the scientific use of water, there is the mental im- 
pression produced by this somewhat unusual mode 
of treatment. 

Massage. — It may be stated in general that mas- 
sage is chiefly applicable to those cases of hysteria, 
often complicated with neurasthenia, in which the 
patient cannot or will not take outdoor exercise. 
No form of massage, mechanical movements, or 
gymnastic exercise can compare with exercise in the 
fields and woods. In many cases first coming under 
treatment there is such muscular weakness that no 
sufficient amount of walking, bicycling, or riding can 
be taken. Then, too, hysterical patients often have 
a disinclination to any form of exercise that cannot 
at first be overcome. Again, certain of the acci- 
dents of hysteria — paralysis, contracture, and the 
like — make voluntary exercise impossible. In such 
cases massage must be employed ; and, by careful 
attention to details, can be made to take, in great 
measure, the part of voluntary exercise. 

It is well to understand at the outset that massage 



258 HYSTERIA: ITS NATURE AND TREATMENT. 

must be performed only by some one who has 
learned the art. Very often, unless the physician is 
watchful, some incompetent attendant will be em- 
ployed to give the patient what is mistaken for 
massage — simple friction of the skin. This rubbing 
is not without some value, but it is far removed from 
scientific massage. 

It would seem that massage has been practised 
from the earliest times. According to Schreiber,* a 
certain system of massage and medical gymnastics 
was known and practised by the Hindus and 
Chinese. Galen gives specific directions for the 
method of employing the different sorts of massage, 
and among the Greeks and Romans it held a high 
place as a therapeutic measure. Perhaps the 
man who gave the greatest impetus to mechano- 
therapy was Ling,f who worked and wrote in the 
early part of the present century. Ling's system 
was chiefly a combination of active and passive 
movements, without any distinct massage as we now 
use this term. This latter addition was introduced 
by the French school some twenty-five years ago. 
Following Schreiber, the effects of massage and 
mechanical movements may be divided into two 
groups. Primary, or mechanical effects, such as the 
removal of exudates, extravasations, and the like. 
With this use of massage we are not now concerned. 
The secondary effects of mechanical movements are 



* " A Manual of Massage." 

| " A Treatise on the General Principles of Gymnastics." 



MASSAGE. 259 

brought about by "increasing the circulation, stimu- 
lating the muscular and nervous systems, by setting 
up molecular changes and producing consequent 
changes in sensation, and by effecting alterations in 
the processes of general nutrition" (Schreiber). 

Bearing in mind the physiology of the flow of 
venous blood and lymph, it will readily be seen how 
greatly massage ought to aid these fluids in their 
somewhat sluggish movements. The venous blood 
and lymph in the smaller vessels depend largely on 
muscular movements to assist their flow, and so, by 
increasing the rate of flow of these fluids, and by 
squeezing the lymph out of the lymph crevices, gen- 
eral nutrition is improved and the muscular and 
nervous systems indirectly stimulated. In addition 
to this there can be no doubt that both muscle and 
nerve are mechanically stimulated by the manipula- 
tions. Weir Mitchell * has shown that massage 
causes a slight, but unmistakable, rise of tempera- 
ture, and J. K. Mitchell f has demonstrated that after 
massage there is a very marked increase in the 
number of the red corpuscles and also of the hema- 
globin, and in some instances an increase of white 
corpuscles. 

Massage should be practised upon the bare skin, 
though some writers advise the patient to be clothed 
in a loose gymnasium suit. The use of vaselin or 
oil is not to be recommended. The various methods 
adopted cannot be described minutely. It may be 

*" Fat and Blood." f Med. News, 1893. 



260 HYSTERIA: ITS NATURE AND TREATMENT. 

said, in general (following Schreiber), that there are 
the following important movements: (i) Pressing 
and kneading with the finger-tips or knuckles. (2) 
Tapping with the hand, fist, or some mechanical 
contrivance. (3) Pinching, which is performed by 
picking up the muscle-bundles that can be grasped. 
Weir Mitchell's * description of the mode of apply- 
ing general massage is so clear and complete that 
it must be quoted verbatim. He says : " An hour 
is chosen midway between two meals, and, the 
patient lying in bed, the manipulator starts at the 
feet and gently but firmly pinches up the skin, roll- 
ing it lightly between his fingers and going carefully 
over the whole foot. Then the toes are bent and 
moved about in every direction, and next with the 
thumbs and fingers, the little muscles of the foot are 
kneaded and pinched more largely, and the inter- 
osseous groups worked at with the finger-tips be- 
tween the bones. At last the whole tissues of the 
foot are seized with both hands and somewhat firmly 
rolled about. Next, the ankles are dealt with in like 
fashion, all the crevices between the articulating 
bones being sought out and kneaded, while the joint 
is put in every possible position. The leg is next 
treated, first, by surface pinching, and then by deeper 
grasping of the areolar tissue, and last by industri- 
ous and deeper pinching of the large muscular 
masses, which for this purpose are put in a position 
of the utmost relaxation. The grasp of the muscles 

*Loc. cit. 



MASSAGE. 261 

is momentary, and for the large muscles of the calf 
and thigh both hands act, the one contracting as the 
other loosens its grip. In treating the firm muscles 
in front of the leg, the fingers are made to roll the 
muscle under the cushions of the finger-tips. At 
brief intervals the manipulator seizes the limb in 
both hands and lightly runs the grasp upward, so as 
to favor the flow of venous blood-currents, and then 
returns to the kneading of the muscles. The same 
process is carried on in every part of the body, and 
especial care is given to the muscles of the loin and 
spine, while usually the face is not touched. The 
belly is first treated by pinching the skin, then by 
deeply grasping and rolling the "muscular walls in 
the hands, and at last the whole belly is kneaded 
with the heel of the hand in a succession of rapid, 
deep movements, passing around in the direction of 
the colon. It depends very much on the strength, 
endurance, and practice of the manipulator, how 
much good is done by these manceuvers. At first, 
or for a few sittings, they are to be very gentle, but 
by degrees they may be made more rough, and if 
the masseur be a good one, it is astonishing how 
much strength may be used without hurting the 
patient. The early treatments should last half an 
hour and should be increased by degrees to one 
hour, after which should follow an hour of absolute 
repose." 

Passive and active movements are sometimes use- 
ful ; in the former, the subject makes no resistance, 
while in the latter variety, the patient, by voluntar- 



262 HYSTERIA : ITS NATURE AND TREATMENT. 

ily contracting certain groups of muscles, antagonizes 
the force employed by the operator and, as it were, 
isolates certain muscle-bundles. This, which is the 
" Swedish " method, is useful in improving the gen- 
eral tone of the muscles, and is particularly adapted 
to the treatment of paralyses and contractures. The 
use of apparatus in the patient's room is often dis- 
tinctly beneficial, and the best device is one of the 
many forms of pulley machines. In employing any 
form of exercise in the treatment of hysteria, it 
must be remembered that the mind must share in 
the exercise as well as the body. As Du Bois Ray- 
mond* well says : "It is plain, therefore, that every 
motion of our body depends not so much upon the 
force of the contractions of the muscles, as upon 
the harmony of their action. To execute any com- 
plex act, as a leap, for instance, each muscle must 
begin to contract at exactly the right moment, and 
the force exerted by each, according to definite laws, 
should increase, continue, and diminish again, in order 
to effect the suitable position of the limbs, and to 
propel, at the proper speed, the center of gravity of 
the body in the desired direction. We have reason 
to believe that, as a rule, the muscle promptly obeys 
the nerve, and that its degree of contractility for 
each movement is determined by the degree of irri- 
tability of the nerve which obtained at the moment 
just preceding. Since the nerves are merely organs 
for the conduction of impulses originating in the 



On Exercise,' : 



MASSAGE. 263 

motor cells, it follows that the actual mechanism of 
every complex motion must have its seat in the cen- 
tral nervous system ; and that, consequently, prac- 
tising exercises is nothing more than schooling 
the central nervous system. All species of bodily 
exercises, therefore, are not simply muscular gym- 
nastics, but nerve gymnastics as well." The golden 
rule to be observed in regard to exercise, whatever 
be its form, is to stop short of actual fatigue. Often 
the good effects of the exercise are more than coun- 
terbalanced by the exhaustion following too pro- 
longed exertion. From this it follows that, in pre- 
scribing exercise, we cannot simply order a certain 
amount, but must be guided by the effect upon the 
individual patient. 



CHAPTER XL 

THE REST CURE.— HYPNOTISM.— SURGICAL 

INTERFERENCE IN THE TREATMENT 

OF HYSTERIA. 

Without giving specific references, which might be 
quoted at great length, it may be said that the gen- 
eral principles of the rest cure have been suggested 
from early times. In many of the older writers we 
find hints of isolation, of feeding, and of massage in 
the treatment of hysteria and allied disorders. It 
may be said that no great discovery has ever been 
announced without precursors of this sort. The 
genius of Weir Mitchell was required to collect, to 
collate, to put in working order, and to make prac- 
tical, the vague suggestions that had gone before. 
To him, therefore, is due the credit of having given 
to us this most valuable form of treatment. Next to 
Weir Mitchell, Playfair * has done most to popular- 
ize this rest cure treatment, and his name is often 
associated with it. Playfair, however, says very can- 
didly, in one of his papers : "I am anxious to bring 
. . . under notice ... a method of dealing 
with certain grave and most intractable forms of 
nervous disorder familiar to all who see much of the 
diseases of women, which I first became acquainted 
with through the study of a remarkable and interest- 
ing little work by Dr. Weir Mitchell, of Philadelphia. 

* " Nerve Prostration and Hysteria," 1883. 
264 



THE REST CURE. 265 

In doing so I have no original contribution to medi- 
cal science to make, — I have simply followed Dr. 
Mitchell's directions." Not only has Dr. Mitchell 
indicated to the profession the plan of treatment 
best adapted to the cases of grave hysteria, but with 
his graceful pen he has endeavored to inculcate in 
the minds of the laity lessons which, if laid to heart, 
would greatly diminish the victims^of this uncomfort- 
able malady. It may be said, in general, that the 
principles underlying the rest treatment are four: 
(1) Isolation. (2) Rest. (3) Forced feeding. (4) 
Passive exercise. Of the four, probably the most 
important is isolation. Charcot* says: "I must 
admit that if I had to assign the first place to any 
specific treatment for hysteria, it would be to isola- 
tion. I cannot too strongly insist upon the capital 
importance that I attach to isolation in the treatment 
of this disease, in which the psychic element plays so 
predominant a role. For fifteen years I have recog- 
nized the importance of this mode of treatment, and 
my daily observations have but confirmed my opin- 
ion. It is necessary to separate hysterical patients 
from their parents, whose influence is particularly 
pernicious." 

An hysterical girl under Charcot's care, who had 
been suffering from many stigmata of the disease, 
particularly hysterical anorexia, once said to him : 
"As long as papa and mama were with me I did 
not think that my disease amounted to much, and, as 



* Op. cit. 
23 



266 HYSTERIA: ITS NATURE AND TREATMENT. 

I had no inclination to eat, I did not eat. As soon, 
however, as I perceived that you were the master, I 
became afraid, and in spite of my repugnance, I 
tried to eat and soon was able to do so." Weir 
Mitchell * says : " It is rare to find any of the class 
of patients I have described (hysterics) so free from 
the influence of their surroundings as to make it 
easy to treat them in their own homes. It is need- 
ful to disentangle them from the meshes of old 
habits, and to remove them from the contact with 
those who have been the willing slaves of their cap- 
rices. I have often made the effort to treat them in 
their own homes, and to isolate them there, but I 
have rarely done so without promising myself that I 
would not again complicate my treatment by any 
such embarrassments." The two quotations given 
above emphasize the extreme importance of complete 
isolation in bad cases. The patient should not be 
allowed to see any members of the family, nor any 
of the numerous friends who especially delight in 
visiting such invalids, and it is impossible to carry 
this out rigidly if the patient remain at home. One 
of the great advantages of strict isolation is, that the 
patient is removed from the sights and sounds of the 
home life, which in very many cases have become 
well-nigh intolerable. At home it is practically im- 
possible to keep the mind of the patient at perfect 
rest. Every sound suggests a train of thoughts 
which are in the main disagreeable, or at least break 

* " Wear and Tear." 



THE REST CURE. 267 

in upon the mental repose. Every jar in the domes- 
tic machinery finds its response in the patient's ner- 
vous system. It is impossible to keep such a patient in 
ignorance of the daily routine of the household, and 
the ringing of the door-bell may furnish material for 
half a day's disagreeable thoughts. Just as we rig- 
idly exclude the light from an inflamed eye, so must 
we keep the irritable nervous system, the exhausted 
nerve centers, free from every stimulus that is liable 
to excite them. The pernicious influence of an hys- 
terical or foolish mother will counteract the effects of 
the most careful and conscientious work on the part 
of the physician, and, as Mitchell says, " There is no 
success until we have broken up the whole daily 
drama of the sick-room, with its little selfishnesses, 
and its craving for sympathy and indulgence." 

From what has been said it is evident that the 
patient must, in most instances, be sent away from 
home, and it is often a difficult matter to decide 
upon a suitable place. As a rule, it is better to 
avoid large hospitals and sanatoriums where there is 
what might be called a " hospital air," and to select 
some smaller institution, or, what is quite as good, a 
room in a quiet boarding-house. The room should 
be of good size, airy, and simply furnished. In some 
very bad cases it is well to keep the room slightly 
darkened for a few days. I can recall a case seen 
in consultation that had been under treatment for 
several weeks in a bright room, and no improve- 
ment was noticed until the room was made dark. 
Later in the treatment it is well to have all the light 



268 HYSTERIA: ITS NATURE AND TREATMENT. 

and sunshine possible. The isolation should for a 
time be absolute, which means that not only must 
the family and friends be excluded, but no communi- 
cation with the outside world must be maintained, 
and no messages or letters brought to the room. 

The next question is as to the nature of the rest. 
In very bad cases this should for a time be absolute. 
The patient should not be allowed to make any 
movements whatever, and should be fed by the 
nurse. In regard to this point, Mitchell says : " In 
some instances I have not permitted the patient to 
turn over in bed without aid, and this I have done 
because sometimes I think no motion desirable, and 
because, sometimes, the moral influence of absolute 
repose is of use." This absolute rest should be 
continued, in the aggravated cases, for two weeks or 
even longer, and then a certain amount of diversion 
may be allowed. This may be attained by permit- 
ting the nurse to read to the patient, or she may be 
allowed to read a little herself. It may be said, in 
passing, that the physician should carefully select 
the books to be read. 

The feeding of the hysterical patient, especially 
where the hysteria is complicated with neurasthenia, 
as these bad cases very often are, is of extreme 
importance. As a rule, the majority of the patients 
have very little appetite, or their appetite is in some 
way perverted. They desire to eat things that are 
indigestible and non-nutritious. It is well to begin 
with a strict milk diet — a glass of milk every two or 
three hours for the first few days. Then the regi- 



THE REST CURE. 269 

men can be gradually increased by the addition of 
eggs and meat. In a short time the patient is able 
to take a full diet, which should consist of a cup of 
black coffee in the morning, upon awakening. In 
an hour, breakfast, which should be generous, — oat- 
meal, rare steak or chops, with bread and butter and 
milk or coffee. In three hours, or between break- 
fast and luncheon, a glass of milk with a biscuit ; 
then dinner or luncheon, preferably the former, for 
it is better for such patients to take the heavy meal in 
the middle of the day. Dinner should be a stout 
meal, — soup, meat, and vegetables, with some simple 
dessert, to be followed by something light three 
hours after, — milk or beef-tea. Then supper at the 
close of the day, and milk again before bedtime. 
Often in bad cases it is well to give milk in the 
night. It is necessary to attend to the bowels and 
give some simple aperient when needed, and some- 
times some preparation of pepsin is beneficial after 
meals. As a rule, no alcoholic drinks should be 
allowed, except perhaps a sound beer or one of the 
malt preparations. The only drugs that are required, 
as a rule, are iron and some simple bitter. Of course, 
the details of the dietetics must be determined in 
each individual case and the bare outline is here 
indicated. In the case of obese hysterics, Mitchell 
has shown it to be an excellent plan to keep them on 
a low diet until they have lost flesh decidedly, and 
then to go to work' and put flesh on again according 
to the methods that have been explained above. As 
the forced feeding and rest are in a certain way 



270 HYSTERIA: ITS NATURE AND TREATMENT. 

incompatible, it is necessary to substitute something 
for exercise, and this place is taken by massage. 
After a few days of rest this is begun, very gradu- 
ally at first, the sittings lasting not more than twenty 
minutes or half an hour, and the length of the 
seance is increased a little daily until the limit of an 
hour is reached. At the same time, either on alter- 
nate days or at different hours on the same day, 
general faradization of the muscles is practised. 

As has been said, each case must be treated indi- 
vidually ; with some patients it is advisable to begin 
voluntary exercise after a week or ten days, while 
with others two or three weeks should intervene be- 
fore permitting it. The voluntary exercise should 
be commenced very gradually, the patient being first 
allowed to perform her own toilet, then to sit up, 
then to walk a prescribed distance. The value of 
the enforced rest is very soon appreciable, and pa- 
tients soon become accustomed to it. As Weir Mit- 
chell * happily expresses it, "From a restless life of 
irregular hours, and probably endless drugging, from 
hurtful sympathy and overzealous care, the patient 
passes to an atmosphere of quiet, to order and con- 
trol, to the system and care of a thorough nurse, to 
an absence of drugs and to a simple diet. The re- 
sult is always at first, whatever it may be afterward, 
a sense of relief, and a remarkable and often a quite 
abrupt disappearance of many of the nervous symp- 
toms. ... If the physician has the force of 



* " Fat and Blood." 



THE REST CURE. 271 

character required to secure the confidence and re- 
spect of his patient, he has also much more in his 
power, and should have the tact to seize the proper 
occasions to direct the thoughts of his patient to the 
lapse from duties to others, and to the selfishness 
which a life of invalidism is apt to bring about. Such 
moral medication belongs to the higher sphere of 
the doctor's duties, and if he means to cure his pa- 
tient permanently he cannot afford to neglect them." 
The cold douche, or the alternate warm and cold 
douche, should be administered as soon as the pa- 
tient is able to stand it. This should be given in the 
morning after the morning coffee. 

It is hardly necessary to point out the suggestive- 
ness of this mode of treatment, since it is so obvi- 
ous. The isolation, the frequent feeding, the mas- 
sage, and electricity, are all suggestive to a high 
degree, and the success of this mode of treatment 
is in no small part due to this suggestive element. 
This rigid rest treatment is applicable only, or mainly, 
to the bad cases, and especially where, in addition 
to the hysteria, there is a certain amount of neuras- 
thenia. It often happens, however, that we want to 
apply the principles of the rest cure without carry- 
ing out strictly all the details of the treatment. 
Under these circumstances it is possible to obtain 
fairly good results from a modified form of rest treat- 
ment. The plan that I have adopted is to write out 
for such patients exactly what is to be done, the hour 
of rising, the times and character of the meals, the 
mode of applying the douche, the restrictions in re- 



272 HYSTERIA: ITS NATURE AND TREATMENT. 

gard to rest and exercise, etc., and see that these 
regulations are strictly carried out. It must be said, 
however, that the results in this modified rest treat- 
ment are often very disappointing, for, as Playfair 
says : " The worse the case is the more easy and 
certain is the cure." 

Hypnotism. — Throughout the foregoing pages 
constant reference has been made to hypnotism, and 
the similarity between this condition and hysteria 
noted. Again, in the discussion of the various 
methods of treatment, attention has been repeatedly 
called to the potency of suggestion in hysterical 
conditions. It may be well, then, to consider the 
subject of hypnotism somewhat in detail, since it 
must cast much light not only on the nature of hys- 
teria, but also afford valuable suggestions as to 
treatment. In the following sketch, liberal use has 
been made of a paper presented to the Medical and 
Chirurgical Faculty of Maryland several years ago.* 
In looking through the earliest literature on the 
subject of hypnotism, after due allowance has been 
made for the play of the modern imagination, it is 
impossible to deny the fact that hypnotism was not 
only recognized but practised in the earliest times 
of which we have any record. The Chaldeans, who 
are accounted among the earliest soothsayers by 
Cicero, had three orders for the study of magic: 
The exorcisers, the sages, and the star-gazers. It 
was their custom to sleep in certain temples in order 

*" Trans. Med. and Chir. Faculty of Maryland," 1889. 



HYPNOTISM. 273 

to acquire their wonderful gift. The ancient Egyp- 
tians were much given to the practice of magic, and 
all through the Old Testament may be found con- 
stant allusions to it. An old French writer, who 
studied the Egyptian hieroglyphics with the view of 
determining to what extent they practised magnet- 
ism, says * : " Magnetism was daily practised in the 
temples of Isis, of Osiris, and Serapis." He goes 
on to say : " In these temples the priests treated the 
sick and cured them, either by magnetic manipula- 
tion, or by some other means producing somnam- 
bulism." Celsus opposed the miracles of Christ on 
the ground that the Egyptian charlatans, for a small 
sum of money, would perform their wonders publicly, 
such as casting out devils and curing diseases by 
blowing in the face of the person afflicted. 

Another Epicurean mentions the same thing, and 
recalls the reproach that the pagans cast up to Christ 
that the temples of the Egyptians had been plund- 
ered and their secrets extracted. In the temples of 
^Esculapius, of which there were a great number in 
Greece, it was the custom to have sleeping-rooms 
where the patients who visited the shrines were ac- 
customed to fall into a deep sleep. When in this 
condition the course of their malady and the neces- 
sary treatment was revealed to them. Aristides 
mentions the fact that the dumb regained speech by 
drinking the waters of the spring at Pergamus. 
The Romans derived their knowledge of magic from 



* " Annales du Magnetisme Animal," 
24 



274 HYSTERIA: ITS NATURE AND TREATMENT. 

the Greeks, and in fact used to consult oracles else- 
where than in their empire. One finds many pas- 
sages in Latin writers clearly pointing to hypnotism ; 
as, for example, this one from Plautus : " How if I 
stroke him slowly with the uplifted hand so that he 
sleep." As we approach the Christian era we see 
undeniable evidences of hypnotism. Galen alludes 
to it and refers to the writings of Hippocrates on 
the same subject. During the middle ages the prac- 
tice of hypnotism passed into the hands of the clergy, 
and was very successfully employed by them. The 
churches took the place of the ancient temples, and 
we see the same practices indulged in. Persons 
who were sick resorted to these churches or to the 
tomb of some saint. One reads of paralyzed per- 
sons suddenly falling into a deep sleep at these 
shrines, and awaking to find themselves cured of 
their infirmities. In spite of the gross superstition 
of this dark age, the study of magnetism was slowly 
advancing. Marcellus Ficinus, born at Florence in 
1433, admitted that certain men were endowed with 
a mysterious power which they could exercise, not 
only over their own bodies, but also over the bodies of 
others. Paracelsus, a little later, makes this candid 
statement: "The imagination can occasion disease 
and cure it. The confidence that one has in amulets 
and charms is the secret of their virtue." " Magic," 
says Lord Bacon, " is the power of the imagination 
of one individual acting upon the body of another." 
The term magnetism came into vogue in the six- 
teenth century. The magnet had been used for the 



HYPNOTISM. 275 

cure of disease very much earlier, for it is mentioned 
by Pliny, Galen, and Avicenna, but the application 
of this term to hypnotic phenomena is not to be 
found before this time. The seventeenth century 
produced many zealous advocates of hypnotism, or, 
as it was then called, magnetism. Robert Flood, of 
England, propounded a very elaborate theory which 
supposed a universal magnetic fluid pervading all 
matter, and somewhat later we find, in the writings 
of Maxwell,* a Scotch physician, the whole of Mes- 
mer's doctrine in embryo. Valentine Greatrakes, 
an Irishman, was celebrated for his cures, and 
Robert Boyle, President of the Royal Society, says 
of him : " Many physicians, noblemen, clergymen, 
etc., testify to the truth of Greatrakes' cures. The 
chief diseases which he cures are blindness, deafness, 
and paralysis. He lays his hands on the part affected, 
and so moves the disease downward." The man 
who gave the greatest impetus to the study of hyp- 
notism, and whose name has been so long associated 
with it, was Mesmer. About the middle of the 
eighteenth century Mesmer began to promulgate his 
doctrines. While he attracted great attention, his 
methods were so clearly those of the charlatan that 
he was regarded with great distrust by the medical 
profession of Vienna, where he was operating, and 
at length he was requested to put an end to his 
nonsense. Justly discouraged by his reception in 
Austria, he went, in 1778, to Paris. Circumstances 



Medicina Magnetica. 



276 HYSTERIA: ITS NATURE AND TREATMENT. 

greatly favored him, for there still lingered in the 
minds of the Parisians memories of Swedenborg, 
and the impressions made by the miracles at the 
tomb of the Diacre Paris were not yet obliterated. 

All Paris was in an uproar over Mesmer, and he 
made many converts in the ranks of the medical 
profession. He adhered to the ancient idea that 
magnetism was a fluid pervading all space and pos- 
sessed of properties similar to those of a magnet, 
and that by it the human body could be acted upon. 
Nothing could exceed the ridiculous nonsense and 
outrageous quackery of Mesmer's seances in Paris. 
One need only read the descriptions of them to see 
that he was the prince of charlatans. In a large 
room carefully covered with mattresses, his patients 
were accustomed to assemble. This room was dark- 
ened, and all the light that was admitted passed 
through stained windows. In the center of this 
room was the baquet, a tub or box of wood, in which 
were placed a number of bottles filled with what was 
supposed to be magnetized water. The tub was 
filled with water, into which were thrown iron filings, 
pulverized glass, and sand. From the tub projected 
pieces of iron wire, and the patients laid hold of 
these and formed a circle around the baquet. The 
ring of subjects was formed by grasping the wire 
which projected from the baquet with one hand, 
while the other hand clasped the hand of the person 
next, the feet, legs, and thighs being closely in con- 
tact with the corresponding parts of the adjoining 
person. When the patients were in a suitable frame 



HYPNOTISM. 277 

of mind, Mesmer, clad in gorgeous apparel, would 
enter the hall, and with an iron wand touch the 
parts of the body that were supposed to be the seat 
of some disease. Very soon these seances became 
notorious as the resort of hysterical men and women, 
and some of the orgies that are described could 
have been possible only in Paris and only at the time 
mentioned. The French Academy investigated 
Mesmer, and a bitter discussion waged for many 
years on the subject of hypnotism. In 1841 James 
Braid, of Manchester, England, began a very care- 
ful examination into the condition known as animal 
magnetism, and demonstrated the part played by 
suggestion. Following Braid were : Grimes, in this 
country ; Esdaile, of Calcutta ; Azam, of Bordeaux ; 
Lassegue, and many others. In 1879 Charcot began 
the study of hypnotism, and his genius put it upon 
the most scientific basis it had as yet occupied. This 
somewhat lengthy historical sketch is necessary in 
order to understand fully the evolution of hypnotism. 
When we come to consider the nature of hyp- 
notism we are launched upon a sea of speculation. 
Rumpf has proposed the theory that the hypnotic 
state is brought about by certain undefined vascular 
changes in the brain. Preyer supposes an oxidiza- 
ble substance formed by the cells of the brain cortex 
under certain conditions, and Brown-Sequard con- 
siders that the explanation of hypnotism is to be 
found in the phenomenon of inhibition. The ex- 
planation of the hypnotic state — if it can be called 
an explanation — which has always seemed most satis- 



278 HYSTERIA: ITS NATURE AND TREATMENT. 

factory to me, is the following : By certain proce- 
dures, our attention, to use a loose term, carrying 
with it volition, is riveted upon a certain object or 
idea, thus leaving the other centers free. Every one 
is familiar with this state of abstraction. When in- 
tently occupied with some object or idea, one re- 
sponds to external stimulation — as brushing a fly 
from the face, for example — or may answer questions 
rationally, although there is no actual consciousness, 
or at least a very dim consciousness of these acts. 
We withdraw, as it were, the will from its work of 
general direction and supervision, and concentrate it 
upon some single thing. One is made to look intently 
at some bright object and told not to let the eyes or 
mind wander from it. Soon the muscles of the eyes 
become fatigued, the mind becomes filled with the idea 
of sleep — suggested by the tired and closing eyes — 
and volition being concerned with keeping the atten- 
tion upon the bright object, cannot intervene to put 
aside the strong suggestion of sleep. Just as in natural 
sleep certain cells are active, as shown by the phe- 
nomenon of dreaming, so in the hypnotic state, with 
volition off duty, or, to speak more exactly, detailed 
for special duty, suggestion enters the mind freely 
and the unreal is received and acted upon as real. 
We do not, of course, know whether or not there 
are any physical changes taking place in the cells of 
the higher centers of the cerebral cortex during this 
peculiar psychic state. This much, however, we do 
know : that hypnotism is a reality ; that it is some 
peculiar modification of the mind which has been 



HYPNOTISM. 279 

observed for centuries. The fact that no sufficient 
explanation of this phenomenon can be given is no 
proof of its unreality. 

That some of the old superstition concerning 
hypnotism still lingers is evident from the frequently- 
asked question, whether the power to induce this 
state is not a peculiar one and resident only in cer- 
tain persons. As has been shown, the subject him- 
self is really responsible for the condition, the hyp- 
notizer merely aiding in the matter of suggestion. 
The more imperative the suggestion or the com- 
mand to sleep, the more likely are they to be received 
and acted upon. The manner of the operator and 
the amount of confidence he begets are important 
factors, and some practice is necessary in the man- 
ner of making suggestions. Beside this, there is no 
more power to produce the hypnotic state in one 
person than in another. When we turn our atten- 
tion to the questions, what kind and what proportion 
of persons are susceptible to the hypnotic influence, 
opinion is considerably at variance. Charcot and 
the Salpetriere school have always maintained that 
true hypnotism is to be seen only in persons who in 
some degree at least are hysterical. This view 
follows naturally from the position taken by this 
same school, that hypnotism and hysteria are closely 
related states. Bernheim and the Nancy school, 
on the other hand, claim that hypnotism can be more 
readily induced in subjects free from hysteria, and 
even go so far as to say that hysterical individuals 
make poor subjects. The weight of evidence, it has 



280 HYSTERIA: ITS NATURE AND TREATMENT. 

always seemed to me, points decidedly toward the 
former of these views ; namely, that, generally 
speaking, true hypnotism is to be found almost ex- 
clusively among the class having what is recognized 
as an hysterical temperament. 

As to the proportion of persons who can be hyp- 
notized, the testimony of different observers varies 
greatly, ranging from 15 per cent by Durand, to 95 
per cent, by Bernheim. Of course, this depends 
upon what is called " hypnotism." It is possible to 
produce a condition of mild lethargy in almost any 
one who will submit to a prolonged sitting, but this 
condition can hardly be called, strictly speaking, 
hypnotism. My own experience has been that not 
more than 10 to 15 per cent, of persons in this 
country can be hypnotized sufficiently to make sug- 
gestion available as a therapeutic measure. 

The methods of inducing hypnotism now in vogue 
are very simple, and the fantastic paraphernalia and 
elaborate system of "passes" of Mesmer and his 
school, and which are still practised by the profes- 
sional hypnotizer, have fallen into disuse among all 
scientific workers. It is simply necessary to have a 
quiet room, not too many inquisitive observers, and 
the hearty co-operation of the subject, and any one 
of the following methods may be pursued. Fixation, 
either by holding some bright object close to the 
subject's eyes, and in such a position that the mus- 
cles of the eyes will be easily fatigued, or by the 
operator requesting the subject to regard him 
steadily, thus fixing the eyes by the gaze. Again, 



HYPNOTISM. 2S1 

many subjects may be hypnotized by simply holding 
the eyes closed and maintaining a slight pressure on 
the globes. A method that I have pursued is to hold 
the patient's hand, making all the time moderate 
pressure on the wrist. Persons easily hypnotized 
may be thrown into the hypnotic condition by listen- 
ing to a watch or other monotonous sound. Many 
instruments have been devised to use in inducing the 
hypnotic state, but any one of the procedures men- 
tioned above will accomplish the same result if the 
operator sufficiently impresses his subject. The 
operator should always explain to the subject what 
is going to be done, and insist with confidence that 
the predicted results will follow. It is generally 
well to prepare the mind of the subject by telling 
him that he must not resist the hypnotic influence, 
but must unreservedly give himself into the opera- 
tor's hands. I have always thought that the reason 
why it is possible to hypnotize a very much larger 
proportion of people in France than in this country 
is that in France every one understands the mean- 
ing of hypnotism, and when the attempt is made to 
induce this state the subject is expecting the well- 
known phenomena. With us, on the other hand, 
few people believe in the genuineness of hypnotism, 
and this skepticism is naturally a great and ofttimes 
a fatal bar to success. The operator should always 
make repeated suggestions to the subject that he is 
going to sleep, and the more emphatically these sug- 
gestions are made the greater is the likelihood of 
success. As soon as the patient is seated and begins 



282 HYSTERIA : ITS NATURE AND TREATMENT. 

to gaze at the bright object held before his eyes, or 
has his eyes closed by the operator, the suggestion 
should be made that he is going to sleep. " You are 
going to sleep ; " " Your eyes are getting heavy ; " 
" You will soon be asleep." And then, as the eyes 
close, " You are sound asleep ; You cannot open 
your eyes ; they are tight shut." These and similar 
suggestions should be continually made. Patients 
who have been often hypnotized by the same opera- 
tor need only be told, " You are asleep," and the 
suggestion is at once received as a fact. The oftener 
a patient is hypnotized by the same operator the 
easier it becomes to induce the hypnotic state. 

If, when attempting to produce hypnotic lethargy, 
the patient begins to laugh and to regard the opera- 
tion as a farce, there is no use in continuing the 
attempt. Patients should be told that the induction 
of hypnotism is a purely therapeutic measure, and 
if they cannot regard it seriously there is no use in 
undertaking the treatment. It may be well just here 
to protest against the dilettanti experiments with 
hypnotism. There can be no doubt that the induc- 
tion of the hypnotic state has a certain tendency 
to favor the occurrence of hysteria, and sometimes 
even more grave mental disturbances. In some 
countries — and it should be in all — laws have been 
enacted preventing the employment of hypnotism 
except by a physician for therapeutic purposes. 
The professional hypnotizer, when his performances 
are not fakes, as they very often are, is capable of 
doing a great deal of harm to nervous and hysterical 



HYPNOTISM. 283 

individuals, the very ones who flock to this sort of 
exhibition. 

Many different modes of classifying the various 
stages of hypnotism have been proposed, but the 
one given by Charcot is the most scientific, and 
serves as a basis for all the others. He divides the 
hypnotic state into three stages: (1) Catalepsy. 
(2) Lethargy. (3) Somnambulism. Catalepsy is 
induced by simple fixation of the eyes upon some 
bright object, or in susceptible persons by a sudden 
noise. One of the "performances" in the Salpe- 
triere was the striking of a gong at some unex- 
pected moment in one of the wards, upon which 
all the susceptible subjects would be thrown into 
the condition of catalepsy, and this sudden fixa- 
tion of their position, no matter what they might 
be doing, often produced very grotesque effects. 
This cataleptic condition is characterized by a wax- 
like immobility. The limbs will remain in any posi- 
tion in which they are placed by the operator, until 
physiological fatigue ensues. It is wonderful, and a 
proof of the genuineness of the phenomenon, that 
such subjects will keep the arms or legs extended 
for twenty or thirty minutes, or even longer. The 
eyes are wide open, and the expression perfectly 
impassive. In this condition there is general cutan- 
eous anesthesia. If the eyes of the subject who has 
been thrown into the cataleptic state be closed for a 
moment, the condition of lethargy is induced. In 
this state the eyes are tight shut, the head sunk 
upon the breast, and there is every indication of 



284 HYSTERIA : ITS NATURE AND TREATMENT. 

profound sleep. The limbs when raised drop back 
as if paralyzed, and there exists complete cutaneous 
anesthesia. In this condition one may observe the 
phenomenon of muscular hyperexcitability. By 
pressing on certain muscles, or on the motor nerves 
controlling them, a strong contraction results, so 
strong that it is impossible to overcome it by force. 
If in this somnambulic state the eyes are opened, 
the condition of catalepsy is re-established. 

The other state, somnambulism, may be induced 
independently by suggestion, or, according to the 
Salpetriere school, may be brought on by making 
slight friction on the top of the head. In this con- 
dition all the senses are very greatly heightened, and 
often the mental faculties share this excitement. In 
this state the subject will perform all sorts of actions 
at the suggestion of the operator, and this is the 
phase that is utilized by the professional hypnotist to 
make the subject go through the various stock paces 
for the amusement of the audience. Such is the 
classification of Charcot, which, as Culliere says, is 
an ideal classification with many exceptions. Lie- 
bault gives six stages, the earlier ones being different 
degrees of somnolence. Bernheim follows Liebault 
and adds three other stages, making nine in all. 
These classifications are merely the three stages of 
Charcot variously subdivided. The fact that Bern- 
heim and his school include certain light somnolent 
conditions under the head of hypnotism, explains 
the very high per cent, of hypnotizable subjects that 
this school claims to have obtained. 



HYPNOTISM. 285 

Many observers unite in saying that it is impossi- 
ble to draw any sharp distinction between the differ- 
ent stages, and that the various phenomena which 
have been mentioned occur without any regular 
order. My own experience has been that the prim- 
ary condition is lethargy, and that the other states 
are merely suggestive phenomena. In a fairly large 
number of experiments the first indication of the 
hypnotic influence has almost invariably been a con- 
dition of lethargy which varied greatly in intensity. 
If this lethargy was deep, then it was possible to 
make the patient pass into catalepsy by simply open- 
ing the eyes. I have never been able to bring about 
somnambulism by making friction upon the head, as 
Charcot describes, and have been able to induce this 
state only by suggestion. In fact, my experiments 
have led me to the conclusion that the fundamental 
principle underlying hypnotism is suggestion. In 
employing any one of the methods above described, 
it has always, in my experience, been necessary to 
make some suggestion in order to bring on any of 
the various hypnotic states. The suggestion that 
most frequently succeeds is that of sleep, and when 
this is effective then any of the other states may be 
very easily induced by making the appropriate sug- 
gestion. The state of lethargy is, of course, brought 
on by suggestion, and catalepsy is simply a sugges- 
tion made by moving the limbs. In like manner, 
the patient may "be told to get up, or to perform 
certain acts, thus virtually putting him into the state 
of somnambulism. I have become satisfied that the 



286 HYSTERIA: ITS NATURE AND TREATMENT. 

friction of the head spoken of above as a means of 
inducing somnambulism is not effective unless the 
patient in some way connects this procedure with 
movement. A very important point to be borne in 
mind is that in France almost every patient that 
enters one of the hospitals, certainly every Parisian, 
is familiar to a greater or less degree with the vari- 
ous procedures of hypnotism, and consequently is 
prepared, as it were, for these well-known sugges- 
tions. In this country, on the other hand, sugges- 
tions must be made verbally and clearly before the 
subject understands the purport of them. 

Charcot has described several minor or inter- 
mediate stages, among which may be mentioned a 
very mild form of lethargy, and also a condition 
which he calls the state of " charm " or " fascination," 
the important feature of these two states being that 
the subject remembers upon awakening all that has 
passed, while in the other states mentioned above 
the period of hypnosis is a perfect blank. It has 
been shown that the hypnotized subject will accept 
and act upon any suggestion that is made. More 
than this, it is possible with certain subjects to make 
what is known as a post-hypnotic suggestion. A 
patient in a condition of hypnosis is told that at a 
certain time he will do such and such things. When 
the time arrives the act is performed without the 
patient knowing why. For example : a subject is 
told, " To-morrow you will go to a certain place and 
perform some act." The subject is awakened and 
knows nothing of this suggestion, but at the ap- 



HYPNOTISM. 287 

pointed time he does what had been told him while 
in the hypnotic state. This post-hypnotic sugges- 
tion has been found to persist for weeks. A nice 
medico-legal question has been raised ; namely, 
whether it is not possible to have crimes committed 
through the influence of this post-hypnotic sugges- 
tion. As a matter of fact, this question has come 
up in the courts both in this country and in France, 
the accused claiming that he was the victim of hyp- 
notic suggestion. It has always seemed to me 
rather doubtful whether the hypnotic suggestion is 
strong enough to make a man commit murder, — to 
overcome the inherent repugnance to such an act. 
Many States have passed laws forbidding the indis- 
criminate use of hypnotism, believing that in it there 
is the possibility of crime. 

The question of the therapeutic value of hyp- 
notism in the treatment of hysteria and allied 
neuroses is still a moot one. There can be no doubt 
of its great utility in the treatment of many of the 
so-called accidents of hysteria — paralysis, contrac- 
tures, mutism, convulsive attacks, and the like. 
When the physician has succeeded in inducing 
hypnosis he should, for some minutes, repeat the 
suggestion that the paralysis or other symptom would 
be gone when the patient would be awakened. 
Again, in the convulsive attack, as has been shown, 
it is often possible to induce hypnosis and the patient 
may be allowed to sleep, or the suggestion may be 
made that when awakened the convulsion will have 
disappeared. Again, in the interparoxysmal period, 



288 HYSTERIA : ITS NATURE AND TREATMENT. 

in the treatment of the general condition, suggestion 
may be made that there will be no more seizures. 
On the whole, it may be said that the use of hypno- 
tism in the treatment of hysteria is discouraging. 
In the first place, by no means all hysterical subjects 
can be hypnotized. Then, of the number that can 
be influenced, a considerable proportion can only 
be slightly hypnotized, not sufficiently so to make 
use of suggestion. Again, it is found that sugges- 
tions made to hysterical subjects are often very 
transient in their effects. The paralyzed arm in a 
few moments eoes back to its original condition. 
On the other hand, cases are met with now and then 
that yield brilliant results after this mode of treat- 
ment. The great value of hypnotism, however, and 
the great service it has done to medicine is that 
it has taught us how to make our treatment of the 
hysterical subject suggestive. We have learned 
how to make suggestions, and have been taught to 
appreciate this mode of managing the hysterical 
subject. The successful treatment of hysteria is a 
suggestion, not now and then as in hypnotic state, 
but continuous ; every element of the treatment is 
directed toward this end. If, then, hypnotism has 
done nothing but this it has amply repaid all the 
time and study that has for so many years been given 
to it. 

Surgical Interference in the Treatment of 
Hysteria. — It has been shown that in the accidents 
of hysteria, such as paralysis and contracture, sur- 
gical interference is entirely unwarrantable. It may 



SURGICAL INTERFERENCE. 289 

happen, in rare instances, that there is actual short- 
ening of the tendons in contracture requiring- tenot- 
omy, but this is altogether exceptionable. Surgical 
operations are rarely ever thought of after the diag- 
nosis of hysteria is made in the case of the two con- 
ditions mentioned above. Far different has been 
the history of operations upon the organs of repro- 
duction for the cure of hysteria. As has been shown, 
the early authors attributed hysteria to the migrations 
of the uterus, and had the operation of hysterectomy 
been known or been possible at the time, it would, 
no doubt, have been frequently resorted to. As it 
was, the treatment of hysteria often had in view the 
supposed disease of the genital organs. " Nubat 
ilia etmorbum effugiet" said Hippocrates, and For- 
estius gives minute directions for the " confricatio 
vulva." These efforts at treatment were simply the 
logical outcome of the ignorance respecting the 
nature of the disease hysteria, and were excusable. 
It is, however, almost incredible that in the light of 
the nineteenth century surgeons should endeavor to 
cure a disease which is admitted to be in the brain 
by operating upon the organs of generation. And 
still the " operating frenzy " is not spent. Just as in 
the cases mentioned in another chapter, in which 
perfectly healthy breasts have been removed for a 
supposed disease which was really in the mind of 
the patient, and as joints have been laid open and 
muscles and tendons cut for hysterical contractures, 
so innumerable healthy ovaries have been removed 
for hysterical pain situated in. this region. Without 
25 



wmm 



2 9 o HYSTERIA: ITS NATURE AND TREATMENT. 

perceiving it, the effort has been made to remove, by 
the knife, an hysterogenic zone. It became obvious, 
after a time, that the mere existence of pain in the 
region of the ovary was not sufficient cause for 
operation, so the endeavor was made to show some 
evidence of disease — a minute cyst or some other 
utterly trivial condition. 

Most of us were familiar a few years ago with 
this sort of "gynecological pathology." After a 
time the view that the ovaries in hysteria were dis- 
eased had to be abandoned. Then the position was 
boldly assumed that the removal of the ovaries, 
though healthy, was good practice in the treatment 
of hysteria and other mental diseases. For a time 
this dictum was vigorously promulgated, and the 
attack upon the healthy ovary in the hysterical sub- 
ject became notorious. In this country, where so 
much attention has been paid to gynecology and so 
little to hysteria, this most unwarrantable operation 
has been resorted to with disgraceful frequency, and 
if it were necessary, long lists of published cases, 
operated on for the cure of some neurosis, could be 
given. Most unfortunately a certain proportion of 
these operations were successful in relieving the 
hysterical symptoms for a time, but for a very dif- 
ferent reason than the one assigned. As has con- 
stantly been pointed out, the central idea in the treat- 
ment of hysteria is suggestion, and our constant aim 
is to make a strong mental impression. Take, now, 
the hysterical woman : let her undergo this most 
grave operation, knowing often a good deal of what 



SURGICAL INTERFERENCE. 291 

removal of the ovaries implies, feeling that her life 
is to undergo a marked change ; let her pass through 
the impressive preparation for the operation, and 
after the operation be kept in bed for several weeks 
and well nourished. Could any more impressive 
treatment be devised ! I have often heard gyne- 
cologists gravely assert that the surgical procedure 
alone was responsible for the success. It is well 
known that the suggestive effects of the operation 
have been successfully employed, the patient being 
prepared, anesthetized, and bandaged up, no opera- 
tion, or sometimes only a slight cut, having been 
made. It is not the place here to discuss the mor- 
tality of the operation for the removal of the ova- 
ries, but one of the arguments that is sometimes 
offered in support of this mode of treating hysteria 
is, that the removal of the ovaries is perfectly safe. 
It mav be said that the statistics from which the 
mortality tables have been taken are generally those 
of very skilful operators. If all the cases operated 
upon by unskilful and ignorant men were included, 
the mortality would show a far higher figure. The 
fact that this unwarrantable operation was for a 
number of years so strongly advocated by many 
able men, spread the fame of it far and wide among 
the laity, and a neurologist is asked in most of his 
bad cases of hysteria whether it had not better be 
resorted to. Again, the cases of complete and per- 
manent cure are limited in number, and must be, 
since the operation has simply for the time acted 
upon the higher brain centers in a suggestive 



292 HYSTERIA: ITS NATURE AND TREATMENT. 

manner, but has not removed the cause of the 
disease. 

In the vast majority of cases the hysterical symp- 
toms return, and often the ovarian pain comes back 
in the place where the ovaries ought to be. I could 
give many cases even from my own experience if 
space permitted. I will refer to two only : one a case 
that has already been mentioned as illustrating hys- 
terical" lethargy. In addition to this symptom the 
girl had anesthesia and very marked hysterogenic 
zones. Ovariotomy was performed upon her, and 
she was dismissed as cured. Some six months or a 
year after I inquired of her mother as to her condi- 
tion, and was told that she had suffered a relapse and 
had been taken to a hospital, where she had been 
entirely cured by electricity. The case has passed 
from my observation, but doubtless the girl has been 
cured in many different ways since. The other case 
was a woman with certain irregular symptoms. She 
had, however, well-marked hysterogenic zones. 
While under my care I discovered a floating kidney. 
She improved somewhat and left the hospital. I next 
saw her in another institution and learned that she 
had had her ovaries removed, but the hysterical 
stigmata were still present. Subsequently another 
surgeon opened her belly the second time and re- 
moved the floating kidney. After all this, she told 
me that she was about in the same condition as 
before the operation. These are two cases taken 
at random, but they illustrate the point. 

Twenty years ago neuroses in women were sup 



SURGICAL INTERFERENCE. 293 

posed to be due to a stenosis of the os uteri, and 
instruments were devised to enlarge this passage. 
After a time this operation fell into disuse and all 
nervous women who had even the most minute tears 
in the cervix were told that this was the source of 
the trouble — the fans et origo of their nervousness. 
Then came the day for trachelorrhaphy, which was 
practised to an absurd degree. Again, the operation 
of removal or cauterization of the clitoris was at 
one time frequently resorted to as a cure for hysteria. 
To-day these operations have sunk into well-merited 
oblivion, except in cases where there is a distinct 
indication for them. They are no longer performed 
for the relief of the purely nervous symptoms. The 
same history might be given of the use and abuse 
of the pessary. In a previous chapter, the attempt 
has been made to show why women are apt to refer 
their ills to the reproductive organs. The mystery 
attached to the organs of generation and the monthly 
discomforts of menstruation make these organs the 
source of suggestion. This explains the extreme 
readiness of hysterical women to submit to opera- 
tions. In hysterical and neurasthenic men it is 
extremely common to hear complaints relative to 
the sexual organs, and yet the operation of castra- 
tion has never been in danger of becoming popular 
among men. The other side of the question — for 
there is another side — which must be considered is 
to what extent actual disease of the reproductive 
organs is responsible for hysteria. It is extremely 
doubtful whether any form of ovarian or uterine 



294 



HYSTERIA: ITS NATURE AND TREATMENT. 



disease ever caused hysteria in a person not pre- 
disposed to this or other neurosis. On the other 
hand, there can be no doubt that ovarian and uterine 
disease or displacement may act as reflex causes and 
thus aggravate the existing hysteria or even bring 
on an attack in individuals predisposed to it. It 
goes without saying that such actual disease of the 
organs of reproduction, or, in fact, any irritating 
cause, should be especially looked after in hysterical 
subjects. 

The rule, then, that should be adopted is that 
operations should not be performed on hysterical 
women for the relief of the nervous symptoms un- 
less some distinct disease of the reproductive organs 
can be detected. 



INDEX 



ABULIA, 149, 163 
Achromatopsia, 79 
Age, influence of, 30 
Aged, hysteria in the, 31 
Amblyopia, 78 
Amyosthenia, 1 13 
Anesthesia, 62 

differential diagnosis of, "J^, 209 

disseminated, 66 

distribution of, 66 

frequency of, 65 

glove and stocking form of, 69 

hemianesthesia, 67 

of mucous membranes, 71 

of special senses, 7 3 

onset of, 72 

reflexes in, 71 

total, 66 

treatment of, 238 

visceral, 71 
Angina pectoris, pseudo- 
Anorexia nervosa, 177 
Aphasia, 192 
Aphonia, 116, 191 
Apoplexy, 113 
Arthralgia, 89 

diagnosis of, 212 
Astasia- abasia, 120 
Atrophy, muscular, 198 
Aura, 130 
Autographism, 195 



BLADDER, irritable, 187 
Blepharospasm, 108 



87 



Breast, hysterical, 87 

differential diagnosis of, 213 



CARDIAC disturbances, 193 
Catalepsy, 162 

hypnotic, 283 
Children, hysteria in, 30 
Clavus hystericus, 86 
Climate, influence of, 31 
Contracture, 96 

and traumatism, 101 
atrophy in, no 
classification of, 102 
differential diagnosis of, 111,215 
hemiplegic form of, 105 
of eye muscles, 107 
of facial muscles, 107 
of involuntary muscles, 108 
of lower extremity, 104 
of upper extremity, 102 
paraplegic form of, 105 
periarticular form of, 105 
treatment of, 240 
Convulsive attacks, 122 

consciousness in, 125 
cry in, 125 

differential diagnosis of, 217 
duration of, 133, 138 
major, or grand attack, 125, 

129 
minor, 123 

prodromes of, 124, 125, 129 
stages of, 129 



295 



296 



INDEX. 



Cough, 190 
Coxalgia, 89 



FEEDING, forced, 268 
Fever, hysterical, 199 
Flagellation, 20 



DEAFNESS, hysterical, 75 

Death in hysteria, 173, 174 

Degeneracy and hysteiia, 156 

Delirium, 136 

Demoniac possessions, 17 

Diagnosis, differential, 204 

from general nervousness, 

207 
from hypochondria, 206 
from neurasthenia, 205 
of anesthesia, 209 
of arthritic affections, 212 
of contracture, 215 
of convulsive attacks, 216 
of hyperesthesia, 211 
of mental affections, 218 
of motor disturbances, 214 
of paralysis, 216 
of visceral and vasomotor 
disturbances, 219 

Diarrhea, nervous, 180 

Diatheses, influence of, 33 

Diet, 268, 226 

Digestive disturbances, 172 

Dyspnea, 189 



ECSTACY, 162, 164 
Edema, hysterical, 196 
Education, effects of, 34 
Electrotherapeutics, 234, 245 
Environment, effects of, 35, 222 
Epidemics of hysteria, 11 
Epilepsy and hysteria, 217 
Esophagus, contracture of, 172 
Etiology, 29 
Exercise, 227 

Eye, affections of muscles of, 107, 
108 



GAIT in hysterical paralysis, 1 14 
Gangrene, hysterical, 196 
Gastric ulcer and hysteria, 176 
Generation, organs of, 187 
Genito-urinary disorders, 183 
Globus hystericus, 87, 108 
Grand attach, 125, 129 
Gynecological operations in hysteria, 
290 



HEADACHE, 86 

Hematemesis, 175 
Hemianesthesia, 67 
Hemianopia, 82, 77 
Hemidrosis, 197 
Hemoptysis, 189 
Heredity, influence of, 32, 221 
Hiccough, 191 
Historical, 9 
Hydrotherapy, 233, 252 
Hyperesthesia, 83 

forms of, 85 

of mucous membranes, 85 

treatment of, 238 
Hypnotism, 272 

modes of inducing, 280 

stages of, 283 

therapeutic value of, 287 
Hypochondria, 144, 206 
Hysteria, the name, 55 

and hypnotism, 135 

lighter forms of, 59 
Hysterical fever, suggestion in, 203 

temperament, 58 
Hystero-epilepsy, 122, 128, 217 
Hysterogenesis, 95 
Hysterogenic zones, 91 



INDEX. 



297 



INTERCOSTAL neuralgia, 87 
Ischuria, 185 
Isolation, 265 



JOINTS, hysterical, 



OLIGURIA, 187 

Ophthalmoplegia, 1 19 
Opisthotonos, 128 
Ovarian compression, 243 

pain, 90 
Ovariotomy in hysteria, 290 



LETHARGY, 159 

hypnotic, 283 
Loss of memory in hvsteria, 



149 



MAGNET, use of, 248 

Mania, hysterical, 15 1 

Marriage, effects of, 230 

Massage, 257 

application of, 260 
physiology of, 259 

Masturbation, 230 

Megalopsia and micropsia, 83 

Meningitis, pseudo-, 87, 212 

Mental condition in hysteria, 141 

Metallotherapy, 251 

Micropsia, 83 

Motor disturbances, 96 

classification of, 97 
differential diagnosis of, 214 
treatment of, 239 

Mucous membranes, involvement of, 
71,85 



NARCOLEPSY, 159 

Negro, hysteria in the, 31, 32 
Nervous dyspepsia, 172 
Neuralgia, 86 

Neurasthenia, hystero-, 20£ 
Nutrition in hysteria, 178, 196, 
199 

26 



PAIN, hysterical, 86 

sense, 64 
Palpitation, 194 
Paralysis, ill 

cause of, 1 12 

differential diagnosis of, 216 

hemiplegic type of, 1 13 

monoplegic type of, 1 16 

of eye muscles, 1 19 

of facial muscles, 1 14 

of pharynx and esophagus, 1 18 

of vocal cords, 117 

onset of, 112 

paraplegic type of, 116 

quadriplegic type of, 116 

reflexes in, 1 15 

tests for, 113 

treatment of, 239 
Paresthesia, 83 
Pathology, 29 
Peritonitis, pseudo-, 182 
Personality, double, 170 
Petit mal and hysteria, 218 
Pica, 178 
Polyopia, 82 
Polyuria, 184 
Pott's disease, pseudo- 
Pregnancy, false, 182 
Pressure sense, 64 
Pseudo-meningitis, 87 
Ptosis, 119 
Pyrexia, hysterical, 199 



RACE, influence of, 



So 



INDEX. 



Reflex irritation, 37, 38 

Respiration, disturbances of, 189 

Rest cure, the, 264 

mode of applying the, 267 
modified, the, 271 



SEA-bathing, 257 

Sensation, modes of testing, 64 

acuity of, in different parts of 
body, 64 
Sex, influence of, 29 
Sexual disturbances, 59 

instinct in hysteria, 59, 229 
Skin, affections of, 195 
Sleep, disturbances of, 59, 149 
Smell, sense of, 74 
Sneezing, 191 

Social conditions, effects of, 36, 37 
Somnambulism, 165 

hypnotic, 284 
Spasm, expiratory, 190 

inspiratory, 191 
Special sense disturbances, treatment 

of, 239 
Stigmatization, 21, 22 
Suicide in hysteria, 158 
Suppression of urine, 186 
Surgical interference in hysteria, 288 
Sweating, 197 
Symptomatology, 56 



TACHYCARDIA, 193 

Taste, sense of, 73 

Theories as to the nature of hysteria, 

Traumatism, influence of, 101, 112 



Treatment, general, 221 

medicinal, 236 

of anesthesia, 238 

of contracture, 240 

of convulsive seizures, 241 

of hyperesthesia, 238 

of paralysis, 239 

of special sense disturbances, 239 

of special symptoms, 238 
Tremor, 96 

classification of, 98 

differential diagnosis of, 214 

duration of, 99 
Trophic manifestations of hysteria, 

196, 197, 198 
Tympanitis, 181 



VAGINISMUS, 85 

Vampirism, 22 

Vigilambulism, 169 

Visceral disturbances, 172, 219 

Visual affections, 77 

fields, constriction of, 78 
reversal of, color fields, 79 

Voice, affections of, 191 

Vomiting, hysterical, 173 



WATER, use of, 254 

mode of applying, 256 
Watering-places, influence of, 256 
Wilderness cure, 231 



YAWNING, 191 



ZONES, hysterogenic, 91 



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Special Catalogue of Dental Books sent free upon application. 

BARRETT. Dental Surgery for General Practitioners and 
Students of Medicine and Dentistry. Extraction of Teeth, 
etc. 3d Edition. Illustrated. Nearly Ready. 

BLODGETT. Dental Pathology. By Albert N. Blodgett, 
m d., late Professor of Pathology and Therapeutics, Boston Dental 
College. 33 Illustrations. $1.25 

FLAGG. Plastics and Plastic Filling, as Pertaining to the Filling 
of Cavities in Teeth of all Grades of Structure. 4th Edition. $4.00 

FILLEBROWN. A Text-Book of Operative Dentistry. 
Written by invitation of the National Association of Dental Facul- 
ties. Illustrated. $2.25 

GORGAS. Dental Medicine. A Manual of Materia Medica and 
Therapeutics. 5th Edition, Revised. Cloth, $4.00; Sheep, $5.00 

HARRIS. Principles and Practice of Dentistry. Including 
Anatomy, Physiology, Pathology, Therapeutics, Dental Surgery, 
and Mechanism. 13th Edition. Revised by F. J. S. Gorgas, m.d., 
d.d.s. 1250 Illustrations. Cloth, $6.00; Leather, $7.00 

HARRIS. Dictionary of Dentistry. Including Definitions of Such 
Words and Phrases of the Collateral Sciences as Pertain to the Art and 
Practice of Dentistry. 5th Edition. Revised and Enlarged by Fer- 
dinand F. S. Gorgas, m d., d.d.s. Cloth, $4.50; Leather, $5.50 

HEATH. Injuries and Diseases of the Jaws. 4th Edition. 187 
Illustrations. #4.50 

HEATH. Lectures on Certain Diseases of the Jaws. 64 
Illustrations. Boards, .50 

RICHARDSON. Mechanical Dentistry. 7th Edition. Thor- 
oughly Revised by Dr. Geo. W. Warren. 647 Illustrations. 
Just Ready. Cloth, $5.00; Leather, $6. 00 

SEWELL. Dental Surgery. Including Special Anatomy and 
Surgery. 3d Edition, with 200 Illustrations. $2.00 

TAFT. Operative Dentistry. A Practical Treatise. 4th Edition. 
100 Illustrations. Cloth, $3.00 ; Leather, $4. 00 

TAFT. Index of Dental Periodical Literature. $2.00 

TALBOT. Irregularities of the Teeth and Their Treatment. 
2d Edition. 234 Illustrations. $3.00 

TOMES. Dental Anatomy. Human and Comparative. 235 Illus- 
trations. 4th Edition. $3-5o 

TOMES. Dental Surgery. 3d Edition. 292 Illustrations. $4.00 

WARREN. Compend of Dental Pathology and Dental Medi- 
cine. With a Chapter on Emergencies. Illustrated. 

.80; Interleaved, $1.25 

WARREN. Dental Prosthesis and Metallurgy. 129 Ills. $1.25 

WHITE. The Mouth and Teeth. Illustrated. .40 

*#* Special Catalogue Dental Books free upon application. 



SUBJECT CATALOGUE. 



DICTIONARIES. 

GOULD. The Illustrated Dictionary of Medicine, Biology, 
and Allied Sciences. Being an Exhaustive Lexicon of Medicine 
and those Sciences Collateral to it: Biology (Zoology and Botany), 
Chemistry, Dentistry, Parmacology, Microscopy, etc., with many 
useful Tables and numerous fine Illustrations. 1633 pages. 3d Ed. 
Sheep or Half Dark Green Leather, $10.00; Thumb Index, $11.00 
Half Russia, Thumb Index, $12.00 

GOULD. The Medical Student's Dictionary. Including all the 
Words and Phrases Generally Used in Medicine, with their Proper 
Pronunciation and Definition, Based on Recent Medical Literature. 
With Tables of the Bacilli, Micrococci, Mineral Springs, etc., of the 
Arteries, Muscles, Nerves, Ganglia, and Plexuses, etc. 10th Edition. 
Rewritten and Enlarged. Completely resetfrom new type. 700pp. 
Half Dark Leather, $3.25 ; Half Morocco, Thumb Index, $4.00 

GOULD. The Pocket Pronouncing Medical Lexicon. (12,000 
Medical Words Pronounced and Defined.) Containing all the Words, 
their Definition and Pronunciation, that the Medical, Dental, or 
Pharmaceutical Student Generally Comes in Contact With; also 
Elaborate Tables of the Arteries, Muscles, Nerves, Bacilli, etc., etc., 
a Dose List in both English and Metric System, etc., Arranged in a 
Most Convenient Form for Reference and Memorizing. 

Full Limp Leather, Gilt Edges, $1.00 ; Thumb Index, $1.25 
50,000 Copies of Gould's Dictionaries Have Been Sold. 
*#* Sample Pages and Illustrations and Descriptive Circulars ot 

Gould's Dictionaries sent free upon application. 

HARRIS. Dictionary of Dentistry. Including Definitions of Such 
Words and Phrases of the Collateral Sciences as Pertain to the Art 
and Practice of Dentistry. 5th Edition. Revised and Enlarged by 
Ferdinand J. S. Gorgas, m.d., d.d.s. Cloth, $4.50; Leather, $5.50 

LONGLEY. Pocket Medical Dictionary. With an Appendix, 
containing Poisons and their Antidotes, Abbreviations used in Pre- 
scriptions, etc. Cloth, .75 ; Tucks and Pocket, $1.00 

CLEVELAND. Pocket Medical Dictionary. 33d Edition. Very 
small pocket size. Cloth, .50 ; Tucks with Pocket, .75 

MAXWELL. Terminologia Medica Polyglotta. By Dr. 
Theodore Maxwell, Assisted by Others. $3.00 

The object of this work is to assist the medical men of any nationality 

in reading medical literature written in a language not their own. 

Each term is usually given in seven languages, viz. : English, French, 

German, Italian, Spanish, Russian, and Latin. 

TREVES AND LANG. German-English Medical Dictionary. 

Half Russia, $3.25 

EAR (see also Throat and Nose). 

HOVELL. Diseases of the Ear and Naso-Pharynx. Includ- 
ing Anatomy and Physiology of the Organ, together with the Treat- 
ment of the Affections of the Nose and Pharynx which Conduce to 
Aural Disease. 122 Illustrations. $5-°° 

BURNETT. Hearing and How to Keep It. Illustrated. .40 

DALBY. Diseases and Injuries of the Ear. 4th Edition. 38 
Wood Engravings and 8 Colored Plates. $2.50 

PRITCHARD. Diseases of the Ear. 3d Edition, Enlarged. 
Many Illustrations and Formula;. Just Ready. $1.50 

WOAKES. Deafness, Giddiness, and Noises in the Head. 
4th Edition. Illustrated. Just Ready. $2.00 



MEDICAL BOOKS. 



ELECTRICITY. 

BIGELOW. Plain Talks on Medical Electricity and Bat- 
teries. With a Therapeutic Index and a Glossary. 43 Illustra- 
tions. 2d Edition. $1.00 
JONES. Medical Electricity. 2d Edition. 112 Illustrations. £2.50 
MASON. Electricity ; Its Medical and Surgical Uses. Numer- 
ous Illustrations. .75 

EYE. 

A Special Circular of Books on the Eye sent free upon application. 

ARLT. Diseases of the Eye. Clinical Studies on Diseases of the 
Eye. Authorized Translation by Lyman Ware, m.d. Illustrated. 

$1-25 

FICK. Diseases of the Eye and Ophthalmoscopy. Trans- 
lated by A. B. Hale, m. d. 157 Illustrations, many of which are in 
colors, and a glossary. Just Ready. Cloth, $4.50 ; Sheep, $5.50 

GOULD AND PYLE. Compend of Diseases of the Eye and 
Refraction. Illustrated. Just Ready. Cloth, .80; Interleaved, $1.00 

GOWERS. Medical Ophthalmoscopy. A Manual and Atlas 
with Colored Autotype and Lithographic Plates and Wood-cuts, 
Comprising Original Illustrations of the Changes of the Eye in Dis- 
eases of the Brain, Kidney, etc 3d Edition. $4.00 

HARLAN. Eyesight, and How to Care for It. Illus. .40 

HARTRIDGE. Refraction. 96 Illustrations and Test Types. 
8th Edition, Enlarged. $150 

HARTRIDGE. On the Ophthalmoscope. 2d Edition. With 
Colored Plate and many Wood-cuts. $1-25 

HANSELL AND BELL. Clinical Ophthalmology. Colored 
Plate of Normal Fundus and 120 Illustrations. $1.50 

MACNAMARA. On the Eye. 5th Edition. Numerous Colored 
Plates, Diagrams of Eye, Wood-cuts, and Test Types. $3-5° 

MORTON. Refraction of the Eye. Its Diagnosis and the Cor- 
rection of its Errors. With Chapter on Keratoscopy and Test 
Types. 6th Edition. $1.00 

OHLEMANN. Ocular Therapeutics. Authorized Translation, 
and Edited by Dr. Charles A. Oliver. In Press. 

PHILLIPS. Spectacles and Eyeglasses. Their Prescription 
and Adjustment. 2d Edition. 49 Illustrations. $1.00 

SWANZY. Diseases of the Eye and Their Treatment. 6th 
Edition, Revised and Enlarged. 158 Illustrations, 1 Plain Plate, 
and a Zephyr Test Card. Just Ready. $3.00 

THORINGTON. Retinoscopy. Illustrated. Just Ready. $1.00 

WALKER. Students' Aid in Ophthalmology. Colored Plate 
and 40 other Illustrations and Glossary. $1.50 



FEVERS. 

COLLIE. On Fevers. Their History, Etiology, Diagnosis, Prog- 
nosis, and Treatment. Colored Plates. $2.00 

GOODALL AND WASHBOURN. Fevers and Their Treat- 
ment. Illustrated. Just Ready. $300 



10 SUBJECT CATALOGUE. 

GOUT AND RHEUMATISM. 

DUCKWORTH. A Treatise on Gout. With Chromo-lithographs 
and Engravings. Cloth, $6.00 

GARROD. On Rheumatism. A Treatise on Rheumatism and 
Rheumatic Arthritis. Cloth, $5.00 

HAIG. Causation of Disease by Uric Acid. A Contribution to 
the Pathology of High Arterial Tension, Headache, Epilepsy, Gout, 
Rheumatism, Diabetes, Bright's Disease, etc. 3d Edition. #3.00 



HEADACHES. 

DAY. On Headaches. The Nature, Causes, and Treatment of 
Headaches. 4th Edition. Illustrated. $1.00 



HEALTH AND DOMESTIC MEDI- 
CINE (see also Hygiene and Nursing). 

BUCKLEY. The Skin in Health and Disease. Illus. .40 

BURNETT. Hearing and How to Keep It. Illustrated. .40 

COHEN. The Throat and Voice. Illustrated .40 

DULLES. Emergencies. 4th Edition. Illustrated. $1.00 
HARLAN. Eyesight and How to Care for It. Illustrated. .40 

HARTSHORNE. Our Homes. Illustrated. .40 

OSGOOD. The Winter and its Dangers. .40 

PACKARD. Sea Air and Bathing. .40 

PARKES. The Elements of Health. Just Ready. $1.25 

RICHARDSON. Long Life and How to Reach It. .40 

WESTLAND. The Wife and Mother. $1.50 

WHITE. The Mouth and Teeth. Illustrated. .40 

WILSON. The Summer and its Diseases. .40 

WOOD. Brain Work and Overwork. .40 

STARR. Hygiene of the Nursery. 5th Edition. $1.00 

CANFIELD. Hygiene of the Sick-Room. $1.25 

HEART. 

SANSOM. Diseases of the Heart. The Diagnosis and Pathology 
of Diseases of the Heart and Thoracic Aorta. With Plates and other 
Illustrations. $6.00 

HISTOLOGY. 

STIRLING. Outlines of Practical Histology. 368 Illustrations. 
2d Edition, Revised and Enlarged. With new Illustrations. $2.00 

STOHR. Histology and Microscopical Anatomy. Translated 
and Edited by A. Shaper, m.d., Harvard Medical School. 268 
Illustrations. Just Ready. $3-oo 



MEDICAL BOOKS 



HYGIENE AND WATER ANALYSIS. 

Special Catalogue of Books on Hygiene sent free upon application. 

CANFIELD. Hygiene of the Sick-Room. A Book for Nurses 
and Others Being a Brief Consideration of Asepsis, Antisepsis, Dis- 
infection, Bacteriology, Immunity, Heating and Ventilation, and 
Kindred Subjects. $1.25 

COPLIN AND BEVAN. Practical Hygiene. A Complete 
American Text-Book. 138 Illustrations. Cloth, $3.25 ; Sheep, $4.25 

FOX. Water, Air, and Food. Sanitary Examinations of Water, 
Air, and Food. 100 Engravings. 2d Edition, Revised. $3. 50 

KENWOOD. Public Health Laboratory Work. 116 Illustra- 
tions and 3 Plates. $2.00 

LEFFMANN. Examination of Water for- Sanitary and 
Technical Purposes. 3d Edition. Illustrated. $1.25 

LEFFMANN. Analysis of Milk and Milk Products. Illus- 
trated. #1.25 

LINCOLN. School and Industrial Hygiene. .40 

MACDONALD. Microscopical Examinations of Water and 
Air. 25 Lithographic Plates, Reference Tables, etc. 2d Ed. $2.50 

McNEILL. The Prevention of Epidemics and the Construc- 
tion and Management of Isolation Hospitals. Numerous Plans 
and Illustrations. $3. 50 

NOTTER AND FIRTH. The Theory and Practice of Hygiene. 
(Being the 9th Edition of Parkes' Practical Hygiene, rewritten and 
brought up to date.) 10 Plates and 135 other Illustrations. 1034 
pages. 8vo. Just Ready. $7.00 

PARKES. Hygiene and Public Health. By Louis C. Parkes, 
m.d. 5th Edition. Enlarged. Illustrated. In Press. 

PARKES. Popular Hygiene. The Elements of Health. A Book 
for Lay Readers. Illustrated. $1 .25 

STARR. The Hygiene of the Nursery. Including the General 
Regimen and Feeding of Infants and Children, and the Domestic 
Management of the Ordinary Emergencies of Early Life, Massage, 
etc. 5th Edition. 25 Illustrations. Just Ready. #1.00 

STEVENSON AND MURPHY. A Treatise on Hygiene. By 
Various Authors. In Three Octave Volumes. Illustrated. 

Vol. I, $6.00; Vol. II, $6.00; Vol. Ill, $5.00 
*** Each Volume sold separately. Special Circular upon application. 

WILSON. Hand-Book of Hygiene and Sanitary Science. 
Wiih Illustrations. 7th Edition. $3.00 

WEYL. Sanitary Relations of the Coal-Tar Colors. Author- 
ized Translation by Henry Leffmann, m.d., ph.d. #1.25 

*** Special Catalogue of Books on Hygiene free upon application. 



JOURNALS, ETC. 



OPHTHALMIC REVIEW. A Monthly Record of Ophthalmic 
Science. Publ. in London. Sample number .25; per annum #3.00 

NEW SYDENHAM SOCIETY PUBLICATION. Three to six 
volumes each year. Circular upon application. Per annum $8.00 



12 SUBJECT CATALOGUE. 

KIDNEY DISEASES. 

THORNTON. The Surgery of the Kidney. 19 Illus. Clo., $1.50 
TYSON. Bright's Disease and Diabetes. With Especial Ref- 
erence to Pathology and Therapeutics. Including a Section on Reti- 
nitis in Bright's Disease. New Edition. In Preparation. 



LUNGS AND PLEURA. 

HARRIS AND BEALE. Treatment of Pulmonary Consump- 
tion. $2.50 

POWELL. Diseases of the Lungs and Pleurae, including 
Consumption. Colored Plates and other Illus. 4th Ed. $4.00 

TUSSEY. High Altitudes in the Treatment of Consumption. 
fust Ready . $ 1 . 50 

MASSAGE. 

KLEEN. Hand-Book of Massage. Authorized translation by 
Mussey Hartwell, m.d., ph.d. With an Introduction by Dr. S. 
Weir Mitchell. Illustrated by a series ol Photographs Made 
Especially by Dr. Kleen for the American Edition. £2.25 

MURRELL. Massotherapeutics. Massage as a Mode of Treat- 
ment. 5th Edition. $125 

OSTROM. Massage and the Original Swedish Move- 
ments. Their Application to Various Diseases of the Body. A 
Manual for Students, Nurses, and Physicians. Third Edition, En- 
larged. 94 Wood Engravings, many of which are original. $1.00 



MATERIA MEDICA AND THERA- 
PEUTICS. 

ALLEN, HARLAN, HARTE, VAN HARLINGEN. A 
Hand-Book of Local Therapeutics, Being a Practical Description 
of all those Agents Used in the Local Treatment of Diseases of the 
Eye, Ear, Nose and Throat, Mouth, Skin, Vagina, Rectum, etc., 
such as Ointments, Plasters, Powders, Lotions, Inhalations, Supposi- 
tories, Bougies, Tampons, and the Proper Methods of Preparing and 
Applying Them. Cloth, $3.00 ; Sheep, $4.00 

BIDDLE. Materia Medica and Therapeutics. Including Dose 
List, Dietary for the Sick, Table of Parasites, and Memoranda of 
New Remedies. 13th Edition, Thoroughly Revised in accord- 
ance with the new U. S. P. 64 Illustrations and a Clinical Index. 

Cloth, $4.00; Sheep, $5. 00 

BRACKEN. Outlines of Materia Medica and Pharmacology. By 
H. M. Bracken, Professor of Materia Medica and Therapeutics 
and of Clinical Medicine, University of Minnesota. £ 2 -75 

DAVIS. Materia Medica and Prescription Writing. $1 .50 

FIELD. Evacuant Medication. Cathartics and Emetics. $1.75 

GORGAS. Dental Medicine. A Manual of Materia Medica and 
Therapeutics. 5th Edition, Revised. $400 

MAYS. Therapeutic Forces ; or, The Action of Medicine in 
the Light of Doctrine of Conservation of Force. $1-25 

MAYS. Theine in the Treatment of Neuralgia. % bound, .50 



MEDICAL BOOKS 13 



NAPHEYS. Modern Therapeutics, gth Revised Edition, En- 
larged and Improved. In two handsome volumes. Edited by Allen 
I. Smith, m.d., and J. Aubrey Davis, m.d. 

Vol. I. General Medicine and Diseases of Children. $4.00 

Vol. II. General Surgery, Obstetrics, and Diseases of Women. £4.00 

POTTER. Hand-Book of Materia Medica, Pharmacy, and 
Therapeutics, including the Action of Medicines, Special Therapeu- 
tics, Pharmacology, etc., including over 600 Prescriptions and For- 
mulae. 6th Edition, Revised and Enlarged. With Thumb Index in 
each copy. Cloth, #4.50; Sheep, #5.50 

POTTER. Compend of Materia Medica, Therapeutics, and 
Prescription Writing, with Special Reference to the Physiologi- 
cal Action of Drugs. 6th Revised and Improved Edition , based upon 
the U. S. P. 1890. .80; Interleaved, $1.25 

SAYRE. Organic Materia Medica and Pharmacognosy. An 
Introduction to the Study of the Vegetable Kingdom and the Vege- 
table and Animal Drugs. Comprising the Botanical and Physical 
Characteristics, Source, Constituents, and Pharmacopeial Prepara- 
tions. With chapters on Synthetic Organic Remedies, Insects In- 
jurious to Drugs, and Pharmacal Botany. A Glossary and 543 Illus- 
trations, many of which are original. $4.00 

WARING. Practical Therapeutics. 4th Edition, Revised and 
Rearranged. Cloth, $2.00; Leather, $3.00 

WHITE AND WILCOX. Materia Medica, Pharmacy, Phar- 
macology, and Therapeutics. 3d American Edition, Revised by 
Reynold W. Wilcox, m.a., m.d., ll.d. Clo., $2.75; Lea., $3.25 



MEDICAL JURISPRUDENCE AND 
TOXICOLOGY. 

REESE. Medical Jurisprudence and Toxicology. A Text-Book 
for Medical and Legal Practitioners and Students. 4th Edition. 
Revised by Henry Leffmann, m.d. Clo. ,$3.00; Leather, $3.50 
" To the student of medical jurisprudence and toxicology it is in- 
valuable, as it is concise, clear, and thorough in every respect." — The 
American Journal of the Medical Sciences. 

MANN. Forensic Medicine and Toxicology. Illus. $6.50 

MURRELL. What to Do in Cases of Poisoning. 7th 

Edition, Enlarged. $1.00 

TANNER. Memoranda of Poisons. Their Antidotes and Tests. 

7th Edition. .75 

MICROSCOPY. 

BEALE, The Use of the Microscope in Practical Medicine. 
For Students and Practitioners,with Full Directions for Examining the 
Various Secretions, etc., by the Microscope. 4th Ed. 500 Illus. $6.50 

BEALE. How to Work with the Microscope. A Complete 
Manual of Microscopical Manipulation, containing a Full Description 
of many New Processes of Investigation, with Directions for Examin- 
ing Objects Under the Highest Powers, and for Taking Photographs 
of Microscopic Objects. 5th Edition. 400 Illustrations, many of 
them colored. $6.50 

CARPENTER. The Microscope and Its Revelations. 7th 
Edition. 800 Illustrations and many Lithographs. #5 .5© 



14 SUBJECT CATALOGUE. 

LEE. The Microtomist's Vade Mecum. A Hand-Book of 
Methods of Microscopical Anatomy. 887 Articles. 4th Edition, 
Enlarged. Just Ready. $4.00 

MACDONALD. Microscopical Examinations of Water and Air. 
25 Lithographic Plates, Reference Tables, etc. 2d Edition. $2.50 

REEVES. Medical Microscopy, including Chapters on Bacteri- 
ology, Neoplasms, Urinary Examination, etc. Numerous Illus- 
trations, some of which are printed in colors. $2.50 

WETHERED. Medical Microscopy. A Guide to the Use of the 
Microscope in Practical Medicine. 100 Illustrations. $2.00 

MISCELLANEOUS. 

BLACK. Micro-Organisms. The Formation of Poisons. A 
Biological Study of the Germ Theory of Disease. .75 

BURNETT. Foods and Dietaries. A Manual of Clinical Diet- 
etics. 2d Edition. $t-Sv 
GOULD. Borderland Studies. Miscellaneous Addresses and 
Essays. i2mo. $2.00 
GOWERS. The Dynamics of Life. .75 
HAIG. Causation of Disease by Uric Acid. A Contribution to 
the Pathology of High Arterial Tension, Headache, Epilepsy, Gout, 
Rheumatism, Diabetes, Bright's Disease, etc. 3d Edition. #3.00 
HARE. Mediastinal Disease. Illustrated by six Plates. #2.00 
HEMMETER. Diseases of the Stomach. Illus. In Press. 
HENRY. A Practical Treatise on Anemia. Half Cloth, .50 
LEFFMANN. The Coal-Tar Colors. With Special Reference to 
their Injurious Qualities and the Restrictions of their Use. A Trans- 
lation of" Theodore Weyl's Monograph. $1.25 
TREVES. Physical Education : Its Effects, Methods, Etc. .75 
LIZARS. The Use and Abuse of Tobacco. .40 
PARR1SH. Alcoholic Inebriety from a Medical Standpoint, 
with Cases. $1.00 
ST. CLAIR. Medical Latin. __ $1.00 

NERVOUS DISEASES. 

BEEVOR. Diseases of the Nervous System and their Treat- 
ment. In Press. 

GOWERS. Manual of Diseases of the Nervous System. A 
Complete Text-Book. 2d Edition, Revised, Enlarged, and in many 
parts Rewritten. With many new Illustrations. Two volumes. 
Vol. I. Diseases of the Nerves and Spinal Cord. Clo. $3.00 ; Sh. #4.00 
Vol. II. Diseases of the Brain and Cranial Nerves ; General and 
Functional Disease. Cloih, $4.00; Sheep, $5.00 

GOWERS. Syphilis and the Nervous System. $1.00 

GOWERS. Diagnosis of Diseases of the Brain. 2d Edition. 
Illustrated. $i-5° 

GOWERS. Clinical Lectures. A New Volume of Essays on the 
Diagnosis, Treatment, etc., of Diseases of the Nervous System. $2.00 

GOWERS. Epilepsy and Other Chronic Convulsive Diseases. 
2d Edition. In Press. 

HORSLEY. The Brain and Spinal Cord. The Structure and 
Functions of. Numerous Illustrations. $2.50 



MEDICAL BOOKS. 15 



OBERSTEINER. The Anatomy of the Central Nervous Or- 
gans. A Guide to the Study of their Structure in Health and Dis- 
ease. 198 Illustrations. $5-5° 
ORMEROD. Diseases of the Nervous System. 66 Wood En- 
gravings. $1.00 
OSLER. Cerebral Palsies of Children. A Clinical Study. $2.00 
OSLER. Chorea and Choreiform Affections. $2.00 
PAGE. Railroad Injuries. With Special Reference to Those of the 
Back and Nervous System. $2.25 
PRESTON. Hysteria and Certain Allied Conditions. Their 
Nature and Treatment. Illustrated. In Press. 
THORBURN. Surgery of the Spinal Cord. Illustrated. $4.00 
■WATSON. Concussions. An Experimental Study of Lesions Aris- 
ing from Severe Concussions. Paper cover / $1.00 
WOOD. Brain Work and Overwork. .40 

NURSING. 

Special Catalogue of Books for Nurses sent free upon application. 

BROWN. Elementary Physiology for Nurses. .75 

CANFIELD. Hygiene of the Sick-Room. A Book for Nurses and 
Others. Being a Brief Consideration of Asepsis, Antisepsis, Disinfec- 
tion, Bacteriology, Immunity, Heating and Ventilation, and Kindred 
Subjects for the Use of Nurses and Other Intelligent Women. $1.25 

CULLINGWORTH. A Manual of Nursing, Medical and Sur- 
gical. 3d Edition with Illustrations. .75 

CULLINGWORTH. A Manual for Monthly Nurses. 3d Ed. .40 

CUFF. Lectures to Nurses on Medicine. 25 Illustrations. $1.00 

DOMVILLE. Manual for Nurses and Others Engaged in At- 
tending the Sick. 8th Edition. With Recipes for Sick-room Cook- 
ery, etc. .75 

FULLERTON, Obstetric Nursing. 40 Ills. 4th Ed. gi.oo 

FULLERTON. Nursing in Abdominal Surgery and Diseases 
of Women. Comprising the Regular Course of Instruction at the 
Training-School of the Women's Hospital, Philadelphia. 2d Edition. 
70 Illustrations. $1.50 

HUMPHREY. A Manual for Nurses. Including General 
Anatomy and Physiology, Management of the Sick-Room, etc. 15th 
Edition. Illustrated. $1.00 

SHA WE. Notes for Visiting Nurses, and all those Interested 
in the Working and Organization of District, Visiting, or 
Parochial Nurse Societies. With an Appendix Explaining the 
Organization and Working of Various Visiting and District Nurse So- 
cieties, by Helen C. Jenks, of Philadelphia. $1.00 

STARR. The Hygiene of the Nursery. Including the General 
Regimen and Feeding of Infants and Children, and the Domestic Man- 
agement of the Ordinary Emergencies of Early Life, Massage, etc. 5th 
Edition. 25 Illustrations. Just Ready. $1.00 

TEMPERATURE CHARTS. For Recording Temperature, Res- 
piration, Pulse, Day of Disease, Date, Age, Sex, Occupation, 
Name, etc. Put up in pads of fifty. Each .50 

VOSWINKEL. Surgical Nursing, in Illustrations. |i.oo 

%* Special Catalogue of Books on Nursing fret upon application. 



16 SUBJECT CATALOGUE. 

OBSTETRICS. 

BAR. Antiseptic Midwifery. The Principles of Antiseptic Meth- 
ods Applied to Obstetric Practice. Authorized Translation by 
Henry D. Fry, m.d. , with an Appendix by the Author. $1.00 

CAZEAUX AND TARNIER. Midwifery. With Appendix by 
Mund6. The Theory and Practice of Obstetrics, including the Dis- 
eases of Pregnancy and Parturition, Obstetrical Operations, etc. 
8th Edition. Illustrated by Chromo-Lithographs, Lithographs, and 
other full-page Plates, seven of which are beautifully colored, and 
numerous Wood Engravings. Cloth, $4.50; Full Leather, $5.50 

DAVIS. A Manual of Obstetrics. Being a Complete Manual for 
Physicians and Students. 2d Edition. 16 Colored and other Plates 
and 134 other Illustrations. $2.00 

JELLETT. The Practice of Midwifery. Illustrated. In Press. 

LANDIS. Compend of Obstetrics. 5th Edition, Revised by Wm. 
H. Wells, Assistant Demonstrator of Clinical Obstetrics, Jefferson 
Medical College. With many Illustrations, .80 ; Interleaved, #1.25. 

SCHULTZE. Obstetrical Diagrams. Being a series of 20 Col- 
ored Lithograph Charts, Imperial Map Size, of Pregnancy and Mid- 
wifery, with accompanying explanatory (German) text illustrated 
by Wood Cuts. 2d Revised Edition. 

Price in Sheets, $26.00 ; Mounted on Rollers, Muslin Backs, $36.00 

STRAHAN. Extra-Uterine Pregnancy. The Diagnosis and 
Treatment of Extra-Uterine Pregnancy. .75 

WINCKEL. Text-Book of Obstetrics, Including the Pathol- 
ogy and Therapeutics of the Puerperal State. Authorized 
Translation by J. Clifton Edgar, a.m., m.d. With nearly 200 Illus- 
trations. Cloth, $5.00; Leather, $6.00 

FULLERTON. Obstetric Nursing. 4th Ed. Illustrated. $1.00 

SHIBATA. Obstetrical Pocket-Phantom with Movable Child 
and Pelvis. Letter Press and Illustrations. gi.co 

PATHOLOGY. 

BLACKBURN. Autopsies. A Manual of Autopsies Designed for 
the Use of Hospitals for the Insane and other Public Institutions. 
Ten full-page Plates and other Illustrations. $ x -25 

BLODGETT. Dental Pathology. By Albert N. Blodgett, 
m.d., late Professor of Pathology and Therapeutics, Boston Dental 
College. 33 Illustrations. $ I - 2 5 

GILLIAM. Pathology. A Hand-Book for Students. 47 Illus. .75 

HALL. Compend of General Pathology and Morbid Anatomy. 
91 very fine Illustrations. .80 ; Interleaved, $1.25 

VIRCHOW. Post-Mortem Examinations. A Description and 
Explanation of the Method of Performing Them in the Dead House 
of the Berlin Charity Hospital, with Special Reference to Medico- 
Legal Practice. 3d Edition, with Additions. .75 

PHARMACY. 

Special Catalogue of Books on Pharmacy sent free upon application. 

COBLENTZ. Manual of Pharmacy. A New and Complete 
Text-Book by the Professor in the New York College of Pharmacy. 
2d Edition, Revised and Enlarged. 437 Illus. Cloth, $3.50 ; Sh., %\ 50 



MEDICAL BOOKS. 



BEASLEY. Book of 3100 Prescriptions. Collected from the 
Practice of the Most Eminent Physicians and Surgeons — English, 
French, and American. A Compendious History of the Materia 
Medica, Lists of the Doses of all the Officinal and Established Pre- 
parations, an Index of Diseases and their Remedies. 7th Ed. $2.00 

BEASLEY. Druggists' General Receipt Book. Comprising 
a Copious Veterinary Formulary, Recipes in Patent and Proprietary 
Medicines, Druggists' Nostrums, etc. ; Perfumery and Cosmetics, 
Beverages, Dietetic Articles and Condiments, Trade Chemicals, 
Scientific Processes, and an Appendix of Useful Tables. 10th Edi- 
tion, Revised. $2.00 

BEASLEY. Pocket Formulary. A Synopsis of the British and 
Foreign Pharmacopoeias. Comprising Standard and Approved 
Formulae for the Preparations and Compounds Employed in Medical 
Practice, nth Edition. $2.00 

PROCTOR. Practical Pharmacy. Lectures on Practical Phar- 
macy. With Wood Engravings and 32 Lithographic Fac-simile 
Prescriptions. 3d Edition, Revised, and with Elaborate Tables of 
Chemical Solubilities, etc. $3-oo 

ROBINSON. Latin Grammar of Pharmacy and Medicine. 
2d Edition. With elaborate Vocabularies. $ J -75 

SAYRE. Organic Materia Medica and Pharmacognosy. An 
Introduction to the Study of the Vegetable Kinsdom and the Vege- 
table and Animal Drugs. Comprising the Botanical and Physical 
Characteristics, Source, Constituents, and Pharmacopeial Prepar- 
ations. With Chapters on Synthetic Organic Remedies, Insects 
Injurious to Drugs, and Pharmacal Botany. A Glossary and 543 
Illustrations, many of which are original. Cloth, £4. 00; Sheep, $5.00 

SCOVILLE. The Art of Compounding. A Text-Book for the 
Student and a Reference Book for the Pharmacist. CI. #2.50; Sh.g3.50 

STEWART. Compend of Pharmacy. Based upon *' Reming- 
ton's Text-Book of Pharmacy." 5th Edition, Revised in Accord- 
ance with the U. S. Pharmacopoeia, 1890. Complete Tables of 
Metric and English Weights and Measures. .80; Interleaved, $1.25 

UNITED STATES PHARMACOPOEIA. l8go. 7 th Decennial 
Revision. Cloth, $2.50 (postpaid, $2.77) ; Sheep, $3.00 (postpaid, 
#3.27); Interleaved, $4.00 (postpaid, $4.50); Printed on one side ot 
page only, unbound, $3.50 (postpaid, $3.90). 

Select Tables from the U. S. P. (1890). Being Nine of the Most 
Important and Useful Tables, Printed on Separate Sheets. Care- 
fully put up in patent envelope. .25 

WHITE AND WILCOX. Materia Medica, Pharmacy, Phar- 
macology, and Therapeutics. 3d American Edition. Revised 
by Reynold W. Wilcox, m.d., ll.d. Cloth, $275; Leather, $3. 25 

POTTER. Hand-Book of Materia Medica, Pharmacy, and 
Therapeutics. 600 Prescriptions and Formulae. 6th Edition. 

Cloth, $4 50; Sheep, $5. 50 

*** Special Catalogue of Books on Pharmacy free upon application. 



PHYSICAL DIAGNOSIS. 

TYSON. Hand-Book of Physical Diagnosis. For Students and 
Physicians. By the Professor of Clinical Medicine in the University 
of Pennsylvania. Illus. 2d Ed., Improved and Enlarged. $125 

MEMMINGER. Diagnosis by the Urine. 23 Illus. $1.00 

2 



18 SUBJECT CATALOGUE. 

PHYSIOLOGY. 

BRUBAKER. Compend of Physiology. 8th Edition, Revised 
and Enlarged. Illustrated. .80; Interleaved, $1.25 

KIRKE. Physiology. (14th Authorized Edition. Dark-Red Cloth.) 
A Hand-Book of Physiology. 14th Edition, Revised and Enlarged. 
By Prof. W. D Halliburton, of Kings College, London. 661 
Illustrations, some of which are printed in colors. Just Ready. 

Cloth, $3.25; Leather, $4.00 

LANDOIS. A Text-Book of Human Physiology, Including 
Histology and Microscopical Anatomy, with Special Reference to 
the Requirements of Practical Medicine. 5th American, translated 
from the 9th German Edition, with Additions by Wm. Stirling, 
m d.,d.sc. 845 lllus., many of which are printed in colors. In Press. 

STARLING. Elements of Human Physiology. 100 Ills. $1.00 

STIRLING. Outlines of Practical Physiology. Including 
Chemical and Experimental Physiology, with Special Reference to 
Practical Medicine. 3d Edition. 289 Illustrations. $2.00 

TYSON. Cell Doctrine. Its History and Present State. $1.50 

YEO. Manual of Physiology. A Text-Book for Students of 
Medicine. By Gerald F. Yeo, m.d., f.r.c.s. 6th Edition. 254 
Illustrations and a Glossary. Cloth, $2.50 ; Leather, $3.00 

PRACTICE. 

BEALE. On Slight Ailments; their Nature and Treatment. 

2d Edition, Enlarged and Illustrated. #1-25 

CHARTERIS. Practice of Medicine. 6th Edition. $2.00 

FOWLER. Dictionary of Practical Medicine. By various 

writers. An Encyclopaedia of Medicine. Go., $3.00; Half Mor. $400 

HUGHES. Compend of the Practice of Medicine. 5th Edition, 

Revised and Enlarged. 

Part I. Continued, Eruptive, and Periodical Fevers, Diseases of the 
Stomach, Intestines, Peritoneum, Biliary Passages, Liver, Kid- 
neys, etc., and General Diseases, etc. 
Part II. Diseases of the Respiratory System, Circulatory System, 
and Nervous System; Diseases of the Blood, etc. 

Price of each part, .80; Interleaved, $1.25 
Physician's Edition. In one volume, including the above two 
parts, a Section on Skin Diseases, and an Index 5th Revised, 
Enlarged Edition. 568 pp. Full Morocco, Gilt Edge, $2 25 

ROBERTS. The Theory and Practice of Medicine. The 
Sections on Treatment are especially exhaustive. 9th Edition, 
with Illustrations. Cloth. $4. 50; Leather, $5. 50 

TAYLOR. Practice of Medicine. Cloth, $2.00; Sheep, $2.50 

TYSON. The Practice of Medicine. By James Tyson, m.d., 
Professor of Clinical Medicine in the University of Pennsylvania. 
A Complete Systematic Text-book with Special Reference to Diag- 
nosis and Treatment. Illustrated. 8vo. Just Ready. 

Cloth, #5.50 ; Leather, $6 50 ; Half Russia, $7.50 

PRESCRIPTION BOOKS. 

BEASLEY. Book of 3100 Prescriptions. Collected from the 
Practice of the Most Eminent Physicians and Surgeons — English, 
French, and American. A Compendious History of the Materia, 
Medica, Lists of the Doses of all Officinal and Established Prepara- 
tions, and an Index of Diseases and their Remedies. 7th Ed. $2.00 



MEDICAL BOOKS. 19 



BEASLEY. Druggists' General Receipt Book. Comprising 
a Copious Veterinary Formulary, Recipes in Patent and Proprie- 
tary Medicines, Druggists' Nostrums, etc. ; Perfumery and Cos- 
metics, Beverages, Dietetic Articles and Condiments, Trade Chem- 
icals, Scientific Processes, and an Appendix of Useful Tables. 
ioth Edition, Revised. $2.00 

BEASLEY. Pocket Formulary. A Synopsis of the British and 
Foreign Pharmacopoeias. Comprising Standard and Approved 
Formulae for the Preparations and Compounds Employed in Medical 
Practice, nth Edition. Cloth, $2. 00 

PEREIRA. Prescription Book. Containing Lists of Terms, 
Phrases, Contractions, and Abbreviations Used in Prescriptions, Ex- 
planatory Notes, Grammatical Construction of Prescriptions, etc. 
16th Edition. Cloth, .75 ; Tucks, $1.00 

WYTHE. Dose and Symptom Book. The Physician's Pocket 
Dose and Symptom Book. Containing the Doses and Uses of all 
the Principal Articles of the Materia Medica and Officinal Prepara- 
tions. 17th Ed. Cloth, .75; Leather, with Tucks and Pocket, $1.00 

SKIN. 

BULKLEY. The Skin in Health and Disease. Illustrated. .40 
CROCKER. Diseases of the Skin. Their Description, Pathol- 
ogy, Diagnosis, and Treatment, with Special Reference to the Skin 
Eruptions of Children. 92 Illus. 2d Edition. Cloth, $4. 50 ; Sh., $5. 50 
IMPEY. Leprosy. 37 Plates. 8vo. #3.50 

VAN HARLINGEN. On Skin Diseases. A Practical Manual 
of Diagnosis and Treatment, with special reference to Differential 
Diagnosis. 3d Edition, Revised and Enlarged. With Formulae 
and 60 Illustrations, some of which are printed in colors. $2.75 

SURGERY AND SURGICAL DIS- 
EASES. 

CAIRD ANDCATHCART. Surgical Hand-Book. 5th Edition, 
Revised. 188 Illustrations. Full Red Morocco, $2.50 

DEAVER. Appendicitis, Its Symptoms, Diagnosis, Pathol- 
ogy, Treatment, and Complications. Elaborately Illustrated 
wiih Colored Plates and other Illustrations. Just Ready. Cloth, $3.50 

DEAVER. Surgical Anatomy. With 200 Illustrations, Drawn by a 
Special Artist from Directions made for the Purpose. In Preparation. 

DULLES. What to Do First in Accidents and Poisoning. 
4th Edition. New Illustrations. $1.00 

HACKER. Antiseptic Treatment of Wounds, Introduction to 
the, According to the Method in Use at Professor Billroth's Clinic, 
Vienna. With a Photo-engraving of Billroth in his Clinic. .50 

HEATH. Minor Surgery and Bandaging, ioth Ed Revised 
and Enlarged. 158 Illustrations, 62 Formulae, Diet List, etc $125 

HEATH. Injuries and Diseases of the Jaws. 4th Edition. 
187 Illustrations. $4 50 

HEATH. Lectures on Certain Diseases of the jaws. 64 Illus- 
trations. Boards, .50 

HORW1TZ. Compend of Surgery and Bandaging, including 
Minor Surgery, Amputations, Fractures, Dislocations, Surgical Dis- 
eases, and the Latest Antiseptic Rules, etc., with Differential Diagno- 
sis and Treatment. 5th Edition, very much Enlarged and Rear- 
ranged. 167 Illustrations, 98 Formulae. Clo.,.8o; Interleaved, $1.25 



SUBJECT CATALOGUE. 



JACOBSON. Operations of Surgery. Over 200 Illustrations. 

Cloth, $3.00 ; Leather, $4.00 
JACOBSON. Diseases of the Male Organs of Generation. 

88 Illustrations. $6.00 

MACREADY. A Treatise on Ruptures. 24 Full-page Litho- 
graphed Plates and Numerous Wood Engravings. Cloth, £6.00 
MAYLARD. Surgery of the Alimentary Canal. 134 illus. $7.50 
MOULLIN. Text-Book of Surgery. With Special Reference to 
Treatment. 3d American Edition. Revised and edited by John B. 
Hamilton, m.d., ll.d., Professor of the Principles of Surgery and 
Clinical Surgery, Rush Medical College, Chicago. 623 Illustrations, 
over 200 of which are original, and many of which are printed in 
colors. Handsome Cloth, $6.00; Leather, $7.00 
" The aim to make this valuable treatise practical by giving special 
attention to questions of treatment has been admirably carried out. 
Many a reader will consult the work with a feeling of satisfaction that 
his wants have been understood, and that they have been intelligently 
met." — The American Journal of Medical Science. 
SMITH. Abdominal Surgery. Being a Systematic Description of 
all the Principal Operations. 224 Illus. 5th Ed. 2 Vols. Clo., $10.00 
SWAIN. Surgical Emergencies. Fifth Edition. Cloth, $1. 75 
VOSWINKEL. Surgical Nursing, in Illustrations. $1.00 
WALSHAM. Manual of Practical Surgery. 5th Ed., Re- 
vised and Enlarged. With 380 Engravings. Clo., $2.75 ; Lea., $3.25 
WATSON. On Amputations of the Extremities and Their 
Complications. 250 Illustrations. $550 



THROAT AND NOSE (see also Ear). 

COHEN. The Throat and Voice. Illustrated. .40 

HALL. Diseases of the Nose and Throat. Two Colored 
Plates and 59 Illustrations. $2.50 

HUTCHINSON. The Nose and Throat. Including the Nose, 
Naso-Pharynx, Pharynx, and Larynx. Illustrated by Lithograph 
Plates and 40 other Illustrations. 2d Edition. In Press. 

MACKENZIE. The Pharmacopoeia of the London Hospital 
for Diseases of the Throat. 5th Edition, Revised by Dr. F. 
G. Harvey. $1 .00 

McBRIDE. Diseases of the Throat, Nose, and Ear. A Clinical 
Manual. With colored Illus. from original drawings. 2d Ed. $6.00 

MURRELL. Chronic Bronchitis and its Treatment. (Author- 
ized Edition.) A Clinical Study. $1.50 

POTTER. Speech and its Defects. Considered Physiologically, 
Pathologically, and Remedially. $1.00 

WOAKES. Post-Nasal Catarrh and Diseases of the Nose 
Causing Deafness. 26 Illustrations. $1.00 



URINE AND URINARY ORGANS. 

ACTON. The Functions and Disorders of the Reproductive 
Organs in Childhood, Youth, Adult Age, and Advanced Life, 
Considered in their Physiological, Social, and Moral Relations. 
8th Edition. #i-75 



MEDICAL BOOKS. 21 



ALLEN. Albuminous and Diabetic Urine. Illus. $2.25 

BROCKBANK. Gallstones. Just Ready. $2.25 

BEALE. One Hundred Urinary Deposits. On eight sheets, 
for the Hospital, Laboratory, or Surgery. Paper, $2.00 

HOLLAND. The Urine, the Gastric Contents, the Common 
Poisons, and the Milk. Memoranda, Chemical and Microscopi- 
cal, for Laboratory Use. Illustrated and Interleaved. 5th Ed. $1.00 
LEGG. On the Urine. 7th Edition, Enlarged. Illus. |i.oo 

MEMMINGER. Diagnosis by the Urine. 23 Illus. $1.00 

MOULLIN. Enlargement of the Prostate. Its Treatment and 
Radical Cure. Illustrated. $150 

THOMPSON. Diseases of the Urinary Organs. 8th Ed. $3.00 
TYSON. Guide to Examination of the Urine. For the Use of 
Physicians and Students. With Colored Plate and Numerous Illus- 
trations engraved on wood. 9th Edition, Revised. $1.25 
VAN NUYS. Chemical Analysis of Healthy and Diseased 
Urine, Qualitative and Quantitative. 39 Illustrations. $1.00 

VENEREAL DISEASES. 

COOPER. Syphilis. 2d Edition, Enlarged and Illustrated with 

20 full-page Plates. $5-°o 

GOWERS. Syphilis and the Nervous System. 1.00 

JACOBSON. Diseases of the Male Organs of Generation. 88 

Illustrations. $6.00 

VETERINARY. 

ARMATAGE. The Veterinarian's Pocket Remembrancer. 
Being Concise Directions for the Treatment of Urgent or Rare Cases, 
Embracing Semeiology, Diagnosis, Prognosis, Surgery, Treatment, 
etc. 2d Edition. Boards, $1. 00 

BALLOU. Veterinary Anatomy and Physiology. 29 Graphic 
Illustrations. .80; Interleaved, $1. 25 

TUSON. Veterinary Pharmacopoeia. Including the Outlines of 
Materia Medica and Therapeutics. 5th Edition. $2.25 



WOMEN, DISEASES OF. 

BYFORD (H. T.). Manual of Gynecology. With 234 Illustra- 
tions, many of which are from original drawings. $2 50 

BYFORD (W. H.). Diseases of Women. 4th Edition. 306 
Illustrations. Cloth, $2.00; Leather, $2. 50 

DUHRSSEN. A Manual of Gynecological Practice. 105 
Illustrations. $ 1 -5° 

LEWERS. Diseases of Women. 146 Illus. 3d Edition. $2.00 

WELLS. Compend of Gynecology. Illus. .80; Interleaved, $1. 25 

WINCKEL. Diseases of Women, Translated by special authority 
of Author, under the Supervision of, and with an Introduction by, 
Theophilus Parvin, m.d. 152 Engravings on Wood. 3d Edition, 
Revised. In Preparation. 

FULLERTON. Nursing in Abdominal Surgery and Diseases 
of Women. 2d Edition. 70 Illustrations. $i-5° 



22 SUBJECT CATALOGUE. 

COMPENDS. 



From The Southern Clinic. 

"We know of no series of books issued by any house that so fully 
meets our approval as these ? Quiz-Compends?. They are well ar- 
ranged, full, and concise, and are really the best line of text-books that 
could be found for either student or practitioner." 



BLAKISTON'S ? QUIZ-COMPENDS? 

The Best Series of Manuals for the Use of Students. 
Price of each, Cloth, .80. Interleaved, for taking Notes, $1.25. 

4®* These Compends are based on the most popular text-books 
and the lectures of prominent professors, and are kept constantly re- 
vised, so that they may thoroughly represent the present state of the 
subjects upon which they treat. 

4®=* The authors have had large experience as Quiz-Masters and 
attaches of colleges, and are well acquainted with the wants of students. 

j&g"" They are arranged in the most approved form, thorough and 
concise, containing over 600 fine illustrations, inserted wherever they 
could be used to advantage. 

-8®* Can be used by students of any college. 

4flSf* They contain information nowhere else collected in such a 
condensed, practical shape. Illustrated Circular free. 

No. 1. POTTER. HUMAN ANATOMY. Fifth Revised and 
Enlarged Edition. Including Visceral Anatomy. Can be used 
with either Morris's or Gray's Anatomy. 117 Illustrations and 16 
Lithographic Plates of Nerves and Arteries, with Explanatory 
Tables, etc. By Samuel O. L. Pottbr, m.d., Professor of the 
Practice of Medicine, Cooper Medical College, San Francisco ; late 
A. A. Surgeon, U. S. Army. 

No. 2. HUGHES. PRACTICE OF MEDICINE. Parti. Fifth 
Edition, Enlarged and Improved. By Daniel E. Hughes, m.d., 
Physician-in-Chief, Philadelphia Hospital, late Demonstrator ot 
Clinical Medicine, Jefferson Medical College, Phila. 

No. 3. HUGHES. PRACTICE OF MEDICINE. Part II. 
Fifth Edition, Revised and Improved. Same author as No. 2. 

No. 4. BRUBAKER. PHYSIOLOGY. Eighth Edition, with 
new Illustrations and a table of Physiological Constants. Enlarged 
and Revised. By A. P. Bkubaker, m.d., Professor of Physiology 
and General Pathology in the Pennsylvania College of Dental 
Surgery ; Demonstrator of Physiology, Jefferson Medical College, 
Philadelphia. 

No. 5. LANDIS. OBSTETRICS. Fifth Edition. By Henry G. 
Landis, m.d. Revised and Edited by Wm. H. Wells, m.d., 
Assistant Demonstrator of Obstetrics, Jefferson Medical College, 
Philadelphia. Enlarged. 47 Illustrations. 

No. 6. POTTER. MATERIA MEDICA, THERAPEUTICS, 
AND PRESCRIPTION WRITING. Sixth Revised Edition 
(U. S. P. 1890). By Samuel O. L. Potter, m.d., Professor of 
Practice, Cooper Medical College, San Francisco ; late A. A. Sur- 
geon, U. S. Army. 



MEDICAL BOOKS. 23 



PQUIZ-COMPENDS ?— Continued. 

No. 7. WELLS. GYNECOLOGY. A New Book. By Wm. 
H. Wells, m.d., Assistant Demonstrator of Obstetrics, JeffersoD 
College, Philadelphia. Illustrated. Just Ready. 

No. 8. GOULD AND PYLE. DISEASES OF THE EYE 
AND REFRACTION. A New Book. Including Treatment 
and Surgery. By George M. Gould, m.d., and W. L. Pyle, 
m.d. With Formulae and Illustrations. 

No. 9. HORWITZ. SURGERY, Minor Surgery, and Bandag- 
ing. Fifth Edition, Enlarged and Improved. By Orville 
Hokwitz, B.S., m.d. .Clinical Professor of Genito-Urinary Surgery 
and Venereal Diseases in Jefferson Medical College ; Surgeon to 
Philadelphia Hospital, etc. With 98 Formulae and 71 Illustrations. 

No. 10. LEFFMANN. MEDICAL CHEMISTRY. Fourth 

Edition. Including Urinalysis, Animal Chemistry, Chemistry of 
Milk, Blood, Tissues, the Secretions, etc. By Henry Leffmann, 
m.d., Professor of Chemistry in Pennsylvania College of Dental 
Surgery and in the Woman's Medical College, Philadelphia. 

No. 11. STEWART. PHARMACY. Fifth Edition. Based upon 
Prof. Remington's Text-Book of Pharmacy. By K. E. Stewart, 
m d., ph.g., late Quiz-Master in Pharmacy and Chemistry, Phila- 
delphia College of Pharmacy; Lecturer at Jefferson Medical 
College. Carefully revised in accordance with the new U. S. P. 

No. 12. BALLOU. VETERINARY ANATOMY AND PHY- 
SIOLOGY. Illustrated. By Wm. R. Ballou, m.d., Professor 
of Equine Anatomy at New York College of Veterinary Surgeons ; 
Physician to Bellevue Dispensary, etc. 29 graphic Illustrations. 

No. 13. WARREN. DENTAL PATHOLOGY AND DEN- 
TAL MEDICINE. Second Edition, Illustrated. Containing 
all the most noteworthy points of interest to the Dental Student 
and a Section on Emergencies. By Geo. W. Warren, d.d.s., 
Chief of Clinical Staff, Pennsylvania College of Dental Surgery, 
Philadelphia. 

No. 14. HATFIELD. DISEASES OF CHILDREN. Second 
Edition. Colored Plate. By Marcus P. Hatfield, Profes- 
sor of Diseases of Children, Chicago Medical College. 

No. 15. HALL. GENERAL PATHOLOGY AND MORBID 
ANATOMY. 91 Illustrations. By H. Newberry Hall, ph.g., 
m.d., Professor of Pathology and Med. Chem., Chicago Post- 
Graduate Medical School ; Mem. Surgical Staff, Illinois Charit- 
able Eye and Ear Infirmary ; Chief of Ear Clinic, Chicago Med. 
College. 

Price, each, Cloth, .80. Interleaved, for taking Notes, $1.25. 

Handsome Illustrated Circular sent free upon application. 

In preparing, revising, and improving Blakiston's ? Qujz-Com- 
pends ? the particular wants of the student have always been kept in 
mind. 

Careful attention has been given to the construction of each sentence, 
and while the books will be found to contain an immense amount of 
knowledge in small space, they will likewise be found easy reading ; 
there is no stilted repetition of words ; the style is clear, lucid, and dis- 
tinct. The arrangement of subjects is systematic and thorough ; there 
is a reason for every word. They contain over 600 illustrations. 



Tyson's 
Practice of 
Medicine. 



Illustrated. 
Just Ready. 



Text-Book of the Practice of Medi- 
cine. With Special Reference to Diagnosis 
and Treatment. By James Tyson, m. d., 
Professor of Clinical Medicine in the Univer- 
sity of Pennsylvania; Physician to the Hos- 
pital of the University and to the Philadelphia 
Hospital ; Fellow of the College of Physicians 
of Philadelphia, etc. 



With Many Useful Illustrations. 

Octavo. 1180 Pages. 

Cloth, $5.50; Sheep, $6.50; Half Russia, $7.50. 



Dr. Tyson's qualifications for writing such a work are 
unequaled. It Is^really the outcome of over thirty years' 
experience in teaching and in private and hospital practice. 
As a teacher he has, while devoting himself chiefly to clini- 
cal medicine, occupied several important chairs, an experi- 
ence that has necessarily widened his point of view and 
added weight to his judgment. 

As an author Dr. Tyson has been more than usually suc- 
cessful, and by his book on " Examination of Urine," many 
thousands of which have been sold, has become known 
throughout the English-speaking world. The success of this 
little book lies in the fact that it is concise, simple, direct, 
broad. It furnishes the desired information and then stops. 
The same style has been largely used in the present work, 
and must be appreciated by the busy man and student. 

Descriptive circular and sample pages upon application. 



